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UNITED STATES OF AMERICA. 



LECTURES ON FEVERS 



DELIVERED AT THE CHICAGO HOMOEOPATHIC 



ADDITIONAL LECTURES 






BY 



JOHN R. KIPPAX, M. D., LL. B. 

PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE AND MEDICAL JURISPRUDENCE 
IN THE CHICAGO HOMCEOPATHIC MEDICAL COLLEGE; LATE CLINICAL LECTURER 
AND VISITING PHYSICIAN TO COOK COUNTY HOSPITAL; MEMBER OF THE 
AMERICAN INSTITUTE OF HOMOEOPATHY; MEMBER OF THE COL- 
LEGE OF PHYSICIANS AND SURGEONS, ONTARIO; AUTHOR 
OF HANDBOOK OF SKIN DISEASES; ETC., ETC. 







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I^ISHO 




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CHICAGO 
GKOSS & DELBRIDGE 

1884 



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Copyrighted 1883, 
BY GBOSS & DELBRTDGE, 

All rights reserved. 



TO THE 

ALUMNI AND STUDENTS 

OF THE 

CHICAGO HOMOEOPATHIC MEDICAL COLLEGE, 

TX WHOSE BEHALF 
THESE LECTURES WERE WRITTEN, 

THIS VOLUME 

IS DEDICATED BY THEIR FRIEND, 

THE AUTHOR. 



PEEFACE. 

These lectures contain the substance of the course on Fevers, 
delivered in the Chicago Homoeopathic Medical College to the 
class of 1882-83. The majority are formulated and enlarged 
from brief notes of extempore lectures, and are thus stripped of 
much of the verbiage incident to the lecture-room. The remain- 
der were not delivered in the course, but have been added in 
order to make the work more complete. 

They are published at the request of students and practition- 
ers, who have been from time to time under my instruction, and 
who have expressed a desire to have them prepared in a conven- 
ient form for reference. They contain information derived by 
careful reading and study, from the different sources referred to 
in the Bibliography, for which I desire to acknowledge my in- 
debtedness, combined with extensive personal observation and 
experience. 

In every instance I have endeavored to render the exposition 
of all the diseases treated of, on a level with the science of our 
day. 

I take special pleasure in expressing my obligation to my 
brother, H. Kippax, C. E., of the Government service, for his 
valuable aid in preparing the drawings for the different temper- 
ature charts and other illustrations contained in the work. 

J. R. KIPPAX. 

Chicago, September, 1883. 



CONTENTS, 



LECTURE I. 

INTBODUCTION. 

PAGE: 

Classification and description of bacteria — Role of bacteria in infectious 

and contagious maladies — Classification of fevers 15- 

LECTURE II. 

SIMPLE CONTINUED FEVER. 

Definition — Synonyms — Etiology — Clinical History— Chart — Analysis of 
Chart — Differential Diagnosis — Prognosis — Treatment — Malarial Fe- 
vers — The Nature of Miasm — Thermometry of Fevers 29 

LECTURE III. 

SIMPLE INTERMITTENT FEVER. 

Definition — Synonyms — History — Clinical History — Types — Chart — 

Analysis of Chart — Morbid Anatomy — Differential Diagnosis 4S 

LECTURE IV. 

SIMPLE INTERMITTENT FEVER. 

Treatment 57 

LECTURE Y. 

SIMPLE REMITTENT FEVER. 

Definition — Synonyms — Historical Notice — Etiology — Clinical History — 
Chart — Analysis of Chart — Morbid Anatomy — Differential Diagnosis 
— Prognosis — Treatment 76 



(ix) 



X CONTENTS. 

LECTURE VI. 
PERNICIOUS FEVER 

Definition — Synonyms — History — Etiology — Clinical History — Chart — 
Analysis of Chart — Morbid Anatomy — Differential Diagnosis — Prog- 
nosis — Treatment 89 

LECTURE VII. 
CHRONIC MALARIAL INFECTION- 

Definition — Synonym — Etiology — Clinical History — Morbid Anatomy- 
Differential Diagnosis — Prognosis — Treatment. Dengue. Defini- 
tion — Synonyms — History — Etiology — Clinical History — Chart — ■ 
Analysis of Chart — Differential Diagnosis — Prognosis — Treatment. 100 

LECTURE VIII. 

TYPHO-MALARIAL FEVER. 

Definition — Synonyms — History — Etiology— Clinical History — The Ma- 
larial Type. The Septic Type — Chart — Analysis of Chart — Morbid 
Anatomy — Differential Diagnosis — Prognosis — Treatment Ill 



LECTURE IX. 

HAY FEVER. 

Definition — Synonyms — History — Etiology — Clinical History — Chart — 

Analysis of Chart — Differential Diagnosis— Prognosis — Treatment.. . 123 



LECTURE X. 



TYPHOID FEVER. 



Definition — Synonyms — History — Geographical Distribution — Etiology — 

Clinical History 136 

LECTURE XL 

TYPHOID FEVER. 

Mild and Abortive Forms — Chart — Analysis of Chart — Duration — Re- 
lapses — Morbid Anatomy — Differential Diagnosis — Prognosis 147 

LECTURE XII. 
TYPHOID FEVER. 

Treatment 172 



CONTENTS. XI 

LECTUEE XIII. 

YELLOW FEVER. 

Definition — Synonyms — History — Geographical Limits — Etiology — Clin- 
ical History — Chart — Analysis of Chart — Morbid Anatomy 195 

LECTUEE XIV, 

YELLOW FEVEK. 

Differential Diagnosis — Prognosis — Treatment 210 

LECTUEE XV. 



CEREBRO-SPINAL FEVER. 

Definition — Synonyms — History — Etiology — Varieties — Clinical History 
— Chart — Analysis of Chart — Complications and Sequels — Morbid 
Anatomy — Differential Diagnosis — Prognosis 223 

LECTUEE XVI. 

CEREBRO-SPIXAL FEVER. 

Treatment,. 239 

LECTUEE XVII. 

INFLUENZA. 

Definition — Synonyms — History — Etiology — Clinical History — Chart- 
Analysis of Chart — Morbid Anatomy — Differential Diagnosis — 
Prognosis — Treatment 253 

LECTUEE XVIII. 

TYPHUS FEVER. 

Definition — Synonyms— History — Geographical Limits — Etiology — Clin- 
ical History — Complications — Chart— Analysis of Chart — Morbid 
Anatomy 272 

LECTUEE XIX. 

TYPHUS FEVER. 

Differential Diagnosis — Prognosis — Treatment 291 

LECTUEE XX. 

RELAPSING FEVER. 

Definition — Synonyms — History — Etiology — Clinical History — Chart — 
Analysis of Chart — Morbid Anatomy — Differential Diagnosis — Prog- 
nosis — Treament 307 



Xll CONTENTS. 

LECTURE XXI. 

SMALL-POX. 

Definition — Synonyms — History — Etiology — Varieties — Clinical History 
— Confluent Small-Pox — Hemorrhagic Small-Pox — Complications — 
Chart— Analysis of Chart 331 

LECTURE XXII. 

SMALL-POX. 

Morbid Anatomy — Differential Diagnosis — Prognosis — Treatment 347 

LECTURE XXIII. 

VARIOLOID AND VACCINATION. 

Cow-Pox. Definition — Synonyms — History — Etiology — Clinical History. 
Horse-Pox. Vaccinia, Definition— Synonym— Clinical His — 
tory — Irregularities — Complications. Inoculation, Definition — 
History — Clinical History — Mortality. Vaccination. Definition- 
History — Prophylactic Influence — Virus — Re- vaccination — Surgery 
of Vaccination. Varioloid. Definition — Synonym — Etiology — 
Clinical History — Chart — Analysis of Chart — Differential Diagnosis 
— Prognosis — Treatment 360 

LECTURE XXIV. 

CHICKEN-POX. 

Definition — Synonyms — History — Etiology — Clinical History — Chart — 
Duration — Differential Diagnosis— Prognosis — Treatment. Miliary 
Fever. Definition — Synonyms — History — Etiology — Clinical His- 
tory — Duration — Morbid Anatomy — Differential Diagnosis — Progno- 
sis — Treatment 371 

LECTURE XXV. 

measles. 

Definition — Synonyms — History — Etiology — Clinical History — Duration 
— Irregular Types — Malignant Measles — Complications and Sequels — 
Chart — Analysis of Chart — Morbid Anatomy 379 

LECTURE XXVI. 

MEASLES. 

Differential Diagnosis — Prognosis— Treatment 390 



CONTENTS. Xlll 

LECTURE XXVII. 

GERMAN MEASLES. 

Definition — Synonyms — History — Etiology — Clinical History — Chart — 

Morbid Anatomy — Differential Diagnosis — Prognosis — Treatment. . . 399 

LECTURE XXVIII. 

SCARLET FEYEE. 

Definition — Synonyms — History — Etiology — Forms — Clinical History — 

Irregularities — Complications and Sequels 404 

LECTURE XXIX. 

SCARLET FEVER. 

Chart — Analysis of Chart — Morbid Anatomy — Differential Diagnosis — 

Prognosis , 414 

LECTURE XXX. 

SCARLET FEVER. 

Treatment 425 

Bibliography , 441 

Index 445 



LECTURES ON FEVERS. 

LECTURE I. 

INTRODUCTORY. 

Gentlemen : — "We will begin the present course of lectures on 
the practice of medicine, by considering the nature of that class 
of human ailments which have from early times been known as 
The Feyees. Special causes, more or less independent in 
character, and possessing vaguely defined properties, appear 
on the record books of the past, as operating to produce out- 
breaks of these maladies. 

To-day, writers on febrile affections are pleased to term the 
morbific agents which give rise to the fevers, and to infectious 
and contagious diseases generally, viruses. The organized nat- 
ure of these viruses, and the exact relation of bacteria as con- 
veyors and originators of contagion, are the problems that are 
now undergoing solution. 

Time, the destroyer of creeds and leveler of unfounded the- 
ories, will afford, if not to us, at least to our successors, a demon- 
stration of the truth or falsity of the popular parasitic ilieory 
of the causes of infectious diseases. 

The medical world has ever been in a state of unrest as to the 
origin of Fevers. Away back in the ages of antiquity, medical 
savants found the ordinary theories entirely insufficient to ac- 
count for the peculiar phenomena attending outbreaks of these 
diseases. Hence we find them conjuring up a " constitidio pes- 
tilens" or a "genus epidemicus" to ease their minds and ex- 
plain the mystery. Astrological influences, electrical displays, 

15 



16 LECTURES ON EEYEKS. 

and atmospheric changes, have each and all been looked to in 
their time, but still in vain. 

The early Roman writers unconsciously touched the key-note 
when they attributed the origin of malarial fevers to the entrance 
of low organisms into the body. But it was left to Leuwen- 
hoek, the father of microscopy, and the Columbus of the new 
world of microscopic flora, to outline the bold hypothesis of a 
coniagium vivum, against which no other valid objection can, 
after the lapse of two centuries, be raised, than that in a number 
of infectious and contagious diseases its existence has not as 
yet been absolutely demonstrated. 

Bacteria (from bakterion, a little rod or staff), the smallest 
and at the same time the simplest and lowest of all living forms, 
were first perceived by Leuwenhoek in 1675. They were at that 
time classed under the general head infusoria, and were for years 
considered as animals and placed at the foot of the series. Their 
correct place in the scale of organisms was given them in 1859 
by M. Davaine, who first demonstrated their vegetable nature, 
and in 1863 made known his discovery of microscopic organisms 
in contagious diseases. 

The positive characteristic that bacteria are not animal be- 
ings, is the fact that concentrated acetic acid, which causes all 
animal tissues to become pale, has no action on bacteria. 

The history of these minute organisms is of more than ordi- 
nary interest to medical men, on account of their close relation 
to the formation and diffusion of viruses, and hence to the pa- 
thogeny, sanitation, and hygienic treatment of a great number 
of human ailments. 

A short description of them here, may not be without profit. 

Botanists, who have most recently occupied themselves with 
bacteria, define them as "cells deprived of chlorophyll, of glob- 
ular, oblong or cylindrical form, sometimes sinuous and twisted, 
reproducing themselves exclusively by transverse division, and 
living in isolated or cellular families;" and though they possess 
affinities which approach them to the algce, yet the absence of 
chlorophyll — which is present in the algae — necessitates their be- 
ing classed among the fungi. 

They exist in their separate state in two principal forms: glob- 
ular bodies, or monads, and bodies more or less filiform, or bac- 
teria, properly so called. 



BACTEKIA. 



17 



M. Cohn, of Breslau, the eminent naturalist and student of 
inferior organisms, recognizes six genera of bacteria: 

Fig. 1. 



0m 



Micrococcus, ball or egg-shaped bacteria. 650 diameters. 

ical Journal.) 



(From Microscop- 



These are the smallest bacteria, and unlike all other forms, 
are not characterized by periods of repose and movement. 

When rapidly multiplying they are frequently found grouped 
in gelatinous masses. 

Fig. 2. 



I^ * * *• • 




^ 



^ 









! < S£^ 




Bacterium, short, rod-like bacteria. 



650 Diameters. 
Journal.) 



(From Microscopical 



Magnin says, bacteria spores are the point of departure of 
epidemic foci, and their extreme lightness explains how readily 
they are disseminated by the wind. 

Fig. 3. 




■jfiggggg iVvyya-ttTtD 




Bacillus, straight, fibre-like bacteria. 650 Diameters. 

Journal.) 



(From Microscopical 



The spirilla are the largest of the bacteria, and attain the 
length of two-tenths of a millimeter, (p. 310) 

The filiform bacteria, and the spirilla, unlike the micrococ- 
ci, are never found in gelatinous masses, but may be found in 
active swarms. 



18 



LECTUEES ON FEVERS. 



As is the case with all living organisms, bacteria possess 
the power of self-propagation. This is done by bi-partition or 
fission. 



Fig. 4. 




Bacillus Malarise, (after Klebs and Tommasi-Crudeli.) 
Fig. 5. 







Vibrio, wavy, curl-like bacteria. 650 Diameters. (From 
Microscopical Journal.) 

Spirochseti are long, flexible, spiral bacteria, 



BACTEEIA. 19 

A great part of the whitish, slime that collects on the teeth is 
composed of vibrios. Vibrios are also found in swarms in chole- 
raic discharges. 

When a bacterium has grown to about double its ordinary 
dimensions, constriction takes place at the middle and it is brok- 
en in two. Each half following the parent cell reaches matu- 



Fig. 6. 




u 



IL 

Spirillum, short, screw-like bacteria. 650 Diameters. (From 
Microscopical Journal.) 

rity in a short time, and similarly divides. So rapidly may this 
division be performed that in one hour the separation may be 
complete. Other things being equal the warmer the atmosphere 
the more rapidly does the division proceed. With a lowering 
temperature it becomes slower and slower and finally ceases at 
the neighborhood of the freezing point. 

The bacterial germs are found to differ widely among them- 
selves as regards their preparedness for development. And the 
degree of preparedness applied to either a ferment, an infection 
or a contagion, decides whether the hatching period shall be 
long or short. 

Kecent experiments concerning the " death-point" of bacteria 
have demonstrated that these organisms are capable of resisting 
even marked changes of temperature, provided the changes are 
not sudden but gradual. They will endure an elevation of tem- 
perature to 130 Q Fahr. or even to 176 Q Fahr. ; and gradual freezing 
only benumbs them, — it does not destroy them. 

And further, it may be stated that even desiccation if not too 
prolonged, will not kill them, but will simply arrest their activ- 
ity. Their vitality is not destroyed, for under favorable condi- 
tions of moisture and warmth, this will again assert itself. The 
tenacity of life exhibited by the micrococci in the virus of con- 
tagious diseases well exemplifies this fact. 



20 LECTUKES ON FEVERS. 

But here, as elsewhere in the study of Biogenesis, it is well 
to bear in mind the difference in resistive power possessed by 
the germ, and by the finished bacterium. For, other things be- 
ing equal, the nearer the germ is to its finished sensitive condi- 
tion, the more readily will it succumb to atmospheric changes. 

Ozone affects bacteria by arresting their formation, while car- 
bonic acid temporarily paralyzes them. Boracic acid kills them* 
by depriving them of oxygen; and one-twentieth per cent, of 
carbQlic acid will effectually prevent their development. 

Bacteria receive their nutriment and respire by " endos- 
motic absorption." They require a certain amount of ivater, ox- 
ygen, carbon and nitrogen, as nutrient material, and a certain 
average degree of temperature for germination. The water they 
take up from the liquids in which they develop, or from the 
damp surfaces on which they are formed. The oxygen they 
take from the atmosphere; hence it follows that without free 
access of air there can be no life and no development. The car- 
bon may be taken from any organic substance containing it, but 
not from carbonic acid. And the nitrogen may be taken in 
the form of either albumen or ammonia. 

Bacterial forms are found everywhere, but develop in masses 
only when decomposition and fermentation or putrefaction are 
present. According to Naegeli, a distinguished German bota- 
nist, they are not the chance companions of putrefaction, but are 
the fungi which produce it. "Putrefaction,," says Cohn, "is a. 
chemical process excited by Bacteria. Death does not as is fre- 
quently supposed, cause putrefaction, but rather it is caused by 
the life of these invisible organisms." 

"■ The whole arrangement of nature is based on this, that the 
body in which life has been extinguished succumbs to dissolu- 
tion, in order that its material may become again serviceable to 
new life. If the amount of material which can be moulded into 
human beings is limited on earth, the same particles of material 
must ever be converted from dead into living bodies in an eter- 
nal circle." 

A striking parallelism exists between the known phenomena 
of putrefaction or fermentation, and those of infectious and 
contagious diseases. But, at the same time, there is an acknowl- 



BACTERIA. 21 

edged difference between the bacteria of contagion and the bac- 
teria of putrefaction. The former are distinguished by their dif- 
ierent form, size, and habits of life. Oftentimes they battle for 
existence with the putrefaction bacteria and are by them exter- 
minated if they are conquered. 

Declat alludes to this parallelism when he says, " the role of 
bacteria is not limited to putrefaction. They also invade the 
living organism and bring in their attack the double character of 
infinite smallness in their apparent means and powerful destruc- 
tive energy in the results. From this source come diseases of 
which man not long since did not know the cause, and which he 
only commences to refer to their veritable origin. For those 
who are au courant with the first steps which she has made in 
this new line of research, with the fecundity of her first glimpses, 
with the richness of her first results, it is not doubtful that she 
will soon succeed in demonstrating the parasitic nature of the 
gravest epidemic maladies." 

Our atmosphere contains few, if any, adult bacteria, but al- 
ways more or less permanent spores, which float in groups or 
clouds, and are presumed to have escaped from sporogenous 
filaments of the bacteria. 

These ultra-microscopic germs or particles,* possessed with a 
power of flotation commensurate with their smallness and light- 
ness, are the supposed origin of all bacterial life. 

Miquel found that the average number of microbes in the air 
is feeble in winter, and augments rapidly in the spring. Kain 
always diminishes the number of true microbes. 

Water contains considerable quantities of bacteria, and more 
especially of germinal particles. The water of our rivers and 
lakes is always fecund and may give birth to several species of 
bacteria. The only waters which do not contain them are those 
■drawn from the very source of the spring, as our artesian and 
mineral spring waters. 

The weight of a bacterium has been calculated at 0.000,000,001,- 
57 milligram. This extreme lightness suggests a possible ex- 
planation of the occasional appearance of new diseases in the 
world. Prof. Cohn considers it not unreasonable to suppose 

* A particle has been denned as " a bit of liquid or solid matter, formed by 
the aggregation of atoms or molecules." An atom or molecule if free, is always 
part of a gas, the particle is never so. 



22 LECTUEES ON EEVEKS. 

that small particles of bacterial dust may, while floating in trie 
atmosphere, be carried up by ascending currents of air beyond 
the attraction of our planet and w ander into space, and though 
chilled by floating for an indefinite time through space, it is 
possible for these particles to at last reach the atmosphere of 
other worlds and find there conditions favorable to their devel- 
opment, multiplication and growth. 

Eeversing the order it is not more unreasonable to suppose that 
germs or particles carried beyond the attraction of other worlds 
may, after moving about in space, eventually reach our atmos- 
phere, and finding it congenial to their development, multiply 
and fill the earth. 

Passing from this desultory description of bacterial life in 
general, to a more direct consideration of the position it occu- 
pies in the causation of infectious and contagious maladies, 
let me say to you that we have as yet little positive knowl- 
edge, but trust the future is pregnant with corroborative 
facts. That advanced guard of the medical profession — its suc- 
cessful workers and profound thinkers — are busy night and day 
at the chaos, and even now the light begins to dawn. In their 
experiments on septicaemia Coze and Feltz were driven to admit 
that "there is a direct relation between the infectious accidents 
and the foreign organisms (micrococci) which play in the blood 
the role of ferments and reproduce themselves." Pasteur, the 
accomplished French experimenter, justly claims the honor of 
being the first to suggest the possibility of the parasitic nature 
of septicaemia. 

Dr. Eklund, of Stockholm, found flat, oval or rounded sporoid- 
al cells, termed plax scindens in the urine and blood of scarlet 
fever patients. The plax scindens multiplies as do bacteria in 
general, and belongs to the order of schizomycetes or cleft-fungi 
as adopted by Naegeli. These cellular bodies are peculiar to- 
scarlet fever, and are not found in any other disease, (p. 405). 

Bacteriform elements have been discovered in the nasal mu- 
cus of measles during the stage of invasion, and active, slender 
rods have been unmistakably noticed in the blood of patients 
suffering from this disease. The parasitic nature of diphtheria 
is to-day acknowledged by all. But it is yet a mooted question 
whether a bacterium or a micrococcus is the agent of contagion. 
The bacillus anthracis has been definitely outlined as the cause- 



oeigin of feveks. 23 

of cliarbon. The virulence of variola has been attributed to a 
bacterium, though the majority of testimony corroborates the 
demonstrations of Chauveau and Klebs, which outline it as 
micrococcus. 

Tigri first demonstrated the presence of bacteria in the blood 
of typhoid fever patients, and more recently Klebs and Eberth 
have found a bacillus which they claim to be the specific virus. 
The latter observers found rod-shaped organisms smaller than 
those of anthrax, in the lymphatic glands and vessels in the 
vicinity of typhoid ulcers. 

Coze and Feltz have shown by experimentation that inoculation 
with the blood of typhoid fever produced in rabbits the charac- 
teristic pathological condition in the glands of Peyer. 

The micrococci frequently found in the dejecta of typhoid 
fever patients cannot be held as characteristic, as they are fre- 
quently seen in the faeces of healthy individuals. 

Obermeier in 1868 discovered certain wavy, thread-like bodies, 
called spirilla, in the blood of relapsing fever patients during 
the access of the fever. 

Neisser, of Leipsic, has discovered a very small bacillus in 
the nodes of the skin in leprosy, and has further discovered 
micrococci in the specific virus of gonorrhoea. A form of schi- 
zomycetes or cleft-fungi has been detected in the pia mater of 
cerebro-spinal fever victims. 

Gerber and Birsch-Hirschf elder have recently found bacterial 
corpuscles covering the valves of the heart in ulcerative endo- 
carditis. Yon Eecklinghausen and Lukomsky have discovered 
a micro-organism in erysipelas. And Friedlander, of Berlin, 
the latest investigator as to pneumonia, has found micro-organ- 
isms in that disease. The latter describes ellipsoidal micrococci 
about a micro-millimeter in length, and one-third less in breadth, 
arranged in pairs or long chains, as being specially abundant 
during the stage of red hepatization. 

Koch, Toussaint and "Watson Cheyne, have recently discov- 
ered the true micro-organism which- induces tubercular dis- 
eases. They describe the tubercle bacillus as being more slen- 
der and pointed than the leprosy bacillus, and as having a length 
of from one-third to one-half the diameter of a red corpuscle. 
These bacilli develop most rapidly at a temperature of from 86° 
Fahr, to 106° Fahr., and in this respect differ markedly from the 



24 LECTURES ON FEVERS. 

bacilli of splenic fever which develop rapidly at low temperatures. 

Professors Klebs and Tommassi-Crudeli, of Borne, Italy, 
claim to have found the malarial microbe — the true bacillus 
malarige. But the recent experiments of Dr. Sternberg, with 
malaria, in the vicinity of New Orleans, appear to only partially 
support their statements. The former found the bacillus mala- 
rise not only in malarial soil, but also in the blood of patients 
suffering from intermittent fever. 

From these results of a few of the experiments made during 
the last decade, you will readily understand why the parasitic 
theory of the origin of infectious and contagious diseases as op- 
posed to the physiologio-chemical, is rapidly gaining support. 
The physiologio-chemical theory, which is supported mainly by 
negative argument, maintains that chemical changes take place 
in the system, producing morbid results, after the introduction 
of the infectious elements into the blood, upon the principle of 
catalysis. 

The germ or parasitic theory maintains that the infectious 
and contagious poisons are living organisms which, being intro- 
duced into the blood, develop arid reproduce themselves, and by 
their development and reproduction give rise to morbid changes 
and groups of symptoms, that are characteristic of types of dis- 
ease. Owing to the present uncertain state of medical knowl- 
edge, and the absence of positive evidence as to the exact nature 
and habits of these organisms, advocates of the germ theory are 
themselves divided on the unity or multiplicity of pathogenic 
fungi. 

One school, at the head of which stands Naegeli, of Munich, 
holds that the same species of fungi, differing in form through 
various generations, both morphologically and physiologically, 
may cause the different infectious and contagious diseases. 
This belief is based principally on the experiments of Buchner 
and Pasteur, who believed that by repeated propagation the 
virulent bacillus anthracis could be changed into a harmless hay 
bacillus, and reversely that the harmless bacillus f ceni could, by 
repeated propagation and culture, be made to possess the viru- 
lent properties of the bacillus anthracis. The recent labors of 
Koch and his pupils have, however, thrown great discredit on 
these experiments by demonstrating that Buchner was not suffi- 
ciently careful in making them. For, by repeated experiments 



ORIGIN OF FEVERS. 25 

the former were able to propagate either bacillus indefinitely, 
without in the slightest degree changing its nature. 

The other school, which is rapidly gaining adherents, and has 
suddenly become the popular one of to-day, holds that each in- 
fectious or contagious disease has its virus in a well-defined and 
separate germ, capable of reproducing itself under favorable 
conditions, and always causing the same morbid changes, and 
producing invariably the same distinct specific disease. 

Clinical experience bears us out in giving greater credence to 
the theory of this latter school. For as far back as we have any 
authentic records, small-pox has always been small-pox, and has 
ever been described as having the same general symptoms which 
characterize it to-day. So it has been with scarlet fever; and so 
it is with measles and the rest. As surely as the mustard plant 
arises from the mustard seed, as surely as the oat springs from 
oat, the peach from the peach, and oaks from little acorns grow, 
so surely does the small-pox virus (or seed) increase and mul- 
tiply into small-pox, the scarlet fever virus into scarlet fever, 
and the typhoid virus into typhoid fever. True it may be that 
some symptoms of these maladies may appear more prominent 
in certain epidemics than in others, and that in the course of 
time certain infectious diseases may have become somewhat 
modified; yet it is equally true that the characteristics of these 
diseases have always remained the same, and that one infectious 
or contagious disease has never been known to be transformed 
into another. Could different forms of the same fungus cause 
these varied ailments, it would be a rational expectation that 
changes from one form to another might take place in the body 
of the patient, that a case beginning as measles might end, say 
as scarlet fever, or perchance small-pox, and that an epidemic 
might readily change its nature during any part of its course. 
Suffice it to affirm that from the dim twilight of antiquity 
down to the present time no such transition has ever been ob- 
served. 

No more striking evidence in favor of the parasitic theory in 
general, and of the specific nature of the separate pathogenic 
germs in particular can be brought forward, than the possession 
of fixed incubation periods by many infectious and contagious 
diseases. The quantity of the virus introduced cannot be the 
cause of the appearance of measles on from the 9th to the 11th 



26 LECTURES ON FEVERS. 

day after the infection, or of the appearance of scarlet fever on 
from the 4th to the 7th day, or of small-pox on from the 10th to 
the 13th day. More probable is it that the virus needs this 
time, after introduction into the system, to develop into a mor- 
bific agent. And in the further progress of the disease it is also 
probable that a portion of the energy of the virus consists in its 
passage from the germ state or particle to that of the finished 
organism. 

Cohnheim has observed that anthrax gives no outward mani- 
festation of its presence until the spores have developed into 
bacilli, and that in trichiniasis ; the fever and the myalgia are not 
noticeable until the intestinal trichinae have developed from 
those eaten with the infected meat, and from these a new gen- 
eration has been hatched. According to this view, Tyndall de- 
fines a contagious disease as "a conflict between the person 
smitten by it and a specific organism which multiplies at his ex- 
pense, appropriating his air andmoisture, disintegrating his tis- 
sues, or poisoning him by decompositions incident to its growth." 
In this connection and at this time, it will not be necessary to 
give more than a passing notice to the once popular but now 
antiquated theory of spontaneous generation — a theory which, 
though born with Aristotle and mouldy with age, never has and 
never can admit of experimental proof. Few are the scientists 
who to-day believe in the possibility of physical conditions ever 
operating to evolve living beings from absolutely dead organic 
matter. That life cannot, at least in this age, arise independ- 
ently of pre-existing life, has become almost a truism. The 
day of belief in vitiated air, foul drains and foetid odors as origi- 
nators of disease is rapidly passing by. We now look upon 
defective drains and cesspools, and a corrupt atmosphere, as 
potent distributers of disease only when the special germ of 
epidemic disorder is present. And notwithstanding this, sani- 
tary science will demand as much, if not more, attention of the 
physician as it has in the past. For though bad air and foul 
drains cannot create disease germs, they possess the power of 
pushing the latter into virulent energy of reproduction, and 
thereby promote the spread of disease, suffering and death. 

" Consider," says Tyndall, speaking of the floating dust of 
the air, " consider the woes which these wafted particles, during 
historic and pre-historic ages, have inflicted on mankind; con- 



CLASSIFICATION OF FEYEES. 27 

sider the slaughter which has hitherto followed that of the bat- 
tlefield, when those bacterial destroyers are let loose, often pro- 
ducing a mortality far greater than that of battle itself; aid to 
this the other conception that in times of epidemic disease the 
self -same floating * matter has mingled with it the special germs 
which produce the epidemic, being thus enabled to sow pesti- 
lence and death over nations and continents. Consider all this 
and you will come with me to the conclusion that all the havoc 
of war ten times multiplied would be evanescent if compared 
with the ravages due to atmospheric dust. This preventible 
destruction is going on to-day, and it has been permitted to go 
on for ages, without a whisper of information regarding its cause 
being vouchsafed to a suffering, sentient world. We have been 
scourged by invisible thongs, attacked from impenetrable am- 
buscades, and it is only to-day that the light of science is being 
let in upon the murderous dominion of our foes. From the 
vantage ground already won we look forward with confident hope 
to the triumph of medical art over scenes of misery and woe." 

Classification of Fevers. — Leaving the general causation of 
this group of diseases, we will proceed to their classification. 
And though a' classification from the parasitic standpoint will 
be the classification of the future, the want of a better knowl- 
edge of the different kinds of microphytes forbids our formulat- 
ing it to-day. So, following the classification heretofore adopted 
in our lectures in this college, we will for convenience of study, 
divide the fevers into the following classes: Miasmatic or In- 
fectious, Miasmatic-Contagious or Contagious-Infectious, and 
Contagious. 

Miasmatic^ Malarial or Infectious Fevers are those fevers 
which are caused by a morbific agent, called a miasm or infec- 
tion, developed exterior to the physical organism. A miasm or 
infection is a virus developed exterior to the body, usually in 
connection with decomposing organic matter, and is capable of 
being diffused through air or water. Miasmatic fevers cannot 
be conveyed from a diseased to a sound individual, but may 
recur frequently. 

Miasmatic- Contagious or Contagious-Infectious Fevers^ 

are those fevers which are caused by a morbific agent developed 
within a diseased organism, but matured and reproduced ex- 



'28 LECTUEES ON FEVERS. 

terior to it in connection with decomposing organic matter. 
Miasmatic-Contagious fevers cannot be conveyed directly from 
the sick to the healthy, but only by the excretions, and by these 
but feebly, until the specific germs have become matured and 
luxuriant from contact with decomposing animal and vegetable 
matter outside the diseased organism. 

Contagious Fevers are those fevers which are caused by a 
morbific agent developed, matured and reproduced, entirely 
within a diseased physical organism. 

A contagion is a virus which has its origin only in a living 
being, and is capable of being carried from one individual to 
another. Contagious fevers can be conveyed either through 
the atmosphere, or directly from the sick to the healthy; and 
they attack the organism usually but once. 

Following this classification we will arrange the fevers as fol- 
lows : 

FIRST CLASS.— (Miasmatic.) 

I. — Intermittent Fever. IV. — Typho-Malarial Fever. 

II. — Eemittent Fever. Y. — Dengue Fever. 

III. — Pernicious Fever. YL— Hay Fever. 

SECOND CLASS.— {Miasmatic-Contagious.) 

I. — Typhoid Fever. III. — Cerebro-spinal Fever. 

II. — Yellow Fever. IY. — Influenza. 

THIRD CLASS.— {Contagious.) 

I. — Typhus Fever. Y. — Miliary Fever. 

II. — Eelapsing Fever. YI. — Measles. 

III. — Small-pox and Yarioloid. VII. — German Measles. 
IV.— Varicella. VIII— Scarlet Fever. 

All these different forms of febrile affections may be either 
epidemic or endemic, but they are seldom, if ever, sporadic. 
They are said to be epidemic, when they attack numerous indi- 
viduals at the"! same time fand in the same way; endemic, when 
they appear continuously in the same district, and sporadic when 
they attack individuals without regard to time and place. 



LECTUBE II. 

Simple Continued Fever. 

I shall this morning, before taking up the history of miasmatie 
diseases, direct your attention to a fever which does not admit 
of a place in our classification, and yet is frequently met with in 
practice. I allude to Simple Continued Fever. 

Definition. — This may be defined to be a non-specific contin- 
ued fever, which runs its course in a few days, and terminates 
in rapid convalescence, presenting no characteristic lesion. 

Synonyms. — It has been variously known and described as 
ephemeral fever, inflammatory fever, sun fever, and heat fever. 
Formerly the name simple continued fever was used as a cloak 
to cover the transient and unmasked, the uncertain and the abor- 
tive cases of fever, that might occur during any epidemic. But 
to-day it is narrowed down, so as to include only those cases of 
continued fever, of whatever length, that are of non-specific ori- 
gin, and are non-symptomatic. 

Etiology. — The causes of this fever are numerous. Among 
them we may mention exposure to extremes of heat and cold, 
over-feeding, emotional excitement, and excessive mental or 
physical fatigue. It occurs more frequently during the sum- 
mer season, and prevails more among children than adults. 

Clinical History. — Simple continued fever presents no pre- 
monitory symptoms. The onset is abrupt. The fever asserts 

(29) 



SO LECTURES ON FEVERS. 

its presence by feelings of lassitude and chilliness, followed by 
a sudden rise in temperature. The skin becomes hot, the pulse 
rapid, and the thirst excessive. More or less headache and 
pain in the limbs are present from the beginning of the attack. 
The bowels are generally constipated, and the urine is dimin- 
ished in quantity, high-colored, and of high specific gravity. 
The tongue is covered with a white coating, and the appetite is 
either lessened or lost. Yomiting is rarely present unless the 
attack is brought on by over-feeding. 

The temperature rise is soon at its height, and may reach 
103° Fahr., or even 105° Fahr., in a few hours. Usually the 
fever is of short duration, and convalescence is almost always 
correspondingly rapid. 

The temperature fall may be either sudden or gradual. The 
fever may terminate in twenty-four hours with a copious perspi- 
ration, by a critical discharge from the bowels, or by a large de- 
posit of urates in the urine. Or it may take from two to ten 
days to run its course, and end by gradual defervescence. 

Simple continued fever presents no characteristic eruption, 
though herpes may be said to occasionally attend it. It is main- 
ly characterized by the sudden onset of the fever, and the rapid- 
ity with which the maximum temperature is reached. 

Wilson, following Murchison, describes four different varieties 
of this form of fever: 

1. The ephemeral variety, which is ushered in suddenly 
with chills, or alternate chills and flushes, followed by high 
fever, intense headache, and a quick, full pulse. The skin is hot 
and the urine scanty and high-colored. The tongue is coated 
white, and there are anorexia and constipation. Great pain in 
the limbs, as from a bruise, is a frequent symptom. An attack 
reaches its acme at night, and usually lasts from twelve to thirty- 
six hours. 

2. The synochal variety, sometimes called and described 
as inflammatory fever. In this form the fever runs high, and 
the pulse is full and bounding. The skin is intensely hot, the 
headache severe, and occasionally accompanied with delirium. 
This variety runs a longer coarse than does the ephemeral, and 
is apt to terminate abruptly with copious perspiration. 

3. The ardent continued fever of the tropics, which oc- 
curs mostly during hot, dry weather, among non-acclimated, 



ASTHENIC SIMPLE FEYEE. 31 

plethoric, young individuals. An attack is generally ushered 
in with a chill, or nausea and vomiting, followed by a high fever, 
quick full pulse, hot skin, intense headache, and great restless- 
ness. Active delirium is apt to appear about the fourth or fifth 
day, and may be followed by unconsciousness or at times coma. 
Convalescence, marked by a copious perspiration and an in- 
creased flow of urine, may set in between the sixth and ninth 
days, or death may take place from a continuance of the coma, 
or from sudden collapse following the subsidence of the fever. 

4. Asthenic simple fever. This form tends to follow excess- 
ive bodily or mental fatigue, and lasts from two to three 
weeks. The fever is less marked, and the temperature rise less 
sudden than in the other varieties. The pulse is generally quick 
but feeble. The tongue is apt to be somewhat coated, and the 
bowels constipated. At night the sleep is more or less dis- 
turbed, and is frequently followed by a slight headache during 
the waking hours. And although the strength of the patient 
gradually fails as the fever runs its course, asthenic simple 
fever seldom, if ever, terminates fatally. 

The Duration. — The ephemeral variety, which occurs most- 
ly in children, often runs its course in a few hours. Mild forms 
of simple continued fever have in temperate climates an average 
duration of from three to six days. And the asthenic variety, 
which is characterized by less active fever, may continue two or 
three weeks. 

ANALYSIS OF CHART. 

The Temperature. — A sudden rise of temperature to 103 ° 
Fahr., or 105 ° Fahr., is, as has been suggested, the characteris- 
tic symptom of simple continued fever. In mild cases the fall 
during convalescence, though sudden, is never so rapid as is the 
rise, during the onset of the fever. Severe cases, or those of 
longer duration, are marked by a more gradual defervescence. 

The Pulse. — The pulse is quick, full, and bounding, in all 
varieties except the asthenic, in which it is quick and feeble. 

The Nervous System. — Chills and rigors, followed by head- 
ache, usually usher in the initial stage. The headache is acute, 
and may be followed by delirium. In the ardent variety the 
delirium may lead to stupor, coma and death. 

The Alimentary Tract. — The appetite is generally lost, and 



32 



LECTUKES ON FEVERS. 



CHAKT I. — Simple Continued Fever. 



Forms : 


Ephemeral, 


Inflammatory, 


Ardent, 


Asthenic. 


Duration: 


2 days, 


3 to 5 or 10 days, 


7 to 10 days, 


14 to 21 days. 


Causes: 


Exposure, fatigue and over-feeding. 


Initial 
Symptoms: 


Chills and rigors, 


Chill, or nausea 
and vomiting, 


Lassitude and 
anorexia. 


Tempera- 
ture: 


Sudden rise to 103° Eahr. or 105° Eahr. 


99 Q to 102°. 


Pulse: 


Quick and full, 


Full and 
bounding, 


Frequent and 
full. 


Frequent and 
feeble. 


Head: 


Intense 
headache, 


Sharp 
headache, 


Intense headache, 
delirium, coma, 


Slight 
headache. 


Tongue: 


White coating, 


Slightly 
furred. 


Stomach: 


Thirst and loss of appetite, 


Nausea and 
vomiting, 


Anorexia. 


Intestinal 
Canal: 


Constipation. 


Urine: 


Scanty, high colored, copious deposit of urates 
during convalescence. 


Extremities 


Pains as from a bruise. 


Skin: 


Intensely hot, copious perspiration during convalescence. 


Prognosis: 


Favorable, Guarded, 


Favorable. 



DIAGNOSIS. 



33 



thirst is quite marked. Yomiting is rarely present. The bow- 
els are usually constipated. 

Fig. 7. 



1 1 

DAY 


i 


o 


3 


M 


E 


M 


E 


M 


E 


1fll" 






f\ 








C — 




/ 


7 








-|(V> C ~ 






\ 








o _ 
1Q1 




/ 




\ 






ion 


/ 


i 




I 


^\ 




— 

99 


/ 








\ 


i 


qs° ~ 


/ 










\ 

















Temperature in Simple Continued Fever ( Wunderlich.) 

The Urine.— The urine is characteristically "febrile" and is 
diminished in quantity. It contains a large quantity of urea, 
and is of high specific gravity, varying during the fever from 
1030 to 1035. During defervescence the quantity of urine rap- 
idly increases, and a copious deposit of urates takes place. 

The Cutaneous Surface.— The skin is hot and dry, and occa- 
sionally erythematous. Herpes is sometimes present upon the 
lips and nose. 

Diagnosis.— The diagnosis, though at times obscure, may as 
a rule be outlined with a certain degree of accuracy. When 
differentiating it from other fevers it is well to remember that 
simple continued fever may occur sporadically, at times when 
no epidemic is prevailing. The majority of the fevers are either 
epidemic or endemic. Simple continued fever is oftener caused 
by over-exertion, over-feeding, or over-heating. It begins ab- 
ruptly, and'is marked by a rapid temperature rise. This, along 
with the absence of an eruption, and of abdominal symptoms, 



34 



LECTURES ON FEVERS. 



should be sufficient to differentiate it from typhoid fever, And 
the freedom from jaundice, from pains in the joints, and from 
enlargement of the liver and spleen, as well as the absence of 
spirilla in the-blood, ought to differentiate it from relapsing or 
spirillum fever. 

Fig. 8. 




Temperature in Simple Continued Fever: more gradual defervescence 

(Wunderlich.) 

Prognosis. — In temperate climates the prognosis is generally 
favorable, as the disease tends to recovery. In tropical regions, 
however, the prognosis is more grave, and death is not an un- 
common occurrence. 

Treatment. — The diet should be light and non-stimulating for 
the milder forms, except in the latter stage of the asthenic, when 
a supporting diet is necessary. Milk, blanc-mange, and light 
broths prove all-sufficient. In long lasting cases, koumyss, wine- 
whey, and egg-nog may be added. Water should form the prin- 
cipal beverage. When fever is high, broken ice on the tongue 
is very grateful. Cold water sponging adds greatly to the comfort 
of the patient, and in severe cases the pack may be resorted to 
with benefit. 



MALARIAL FEVERS. 35 

Aconite. — The therapeutics of simple continued fever may be 
expressed in few words. In the ephemeral variety we need no 
other remedy than aconite. And in the ardent variety, accord- 
ing to our East India confreres, it is a most potent aid. It is 
specially indicated when the pulse is very quick, hard and 
sharp. 

Camphor may be useful during the first hours of the fever, 
especially when the attack is caused by exposure to sudden 
changes of temperature. 

Gelseniium is indicated when taking cold is the cause, and 
there is great nervous restlessness, with a quick, large, soft pulse. 

Teratrum vir. is adapted to all forms, with the exception of 
the asthenic. It is particularly beneficial when there is a hard, 
full, quick, bounding, incompressible pulse, with headache, dim- 
ness of vision, nausea, and extreme restlessness. 

Bryonia is called for when the shooting pains in the limbs 
prove distressing to the patient, and especially when accompa- 
nied by a heavy, stupefying headache, aggravated by motion. 
The bryonia fever is mostly caused by cold or error in diet, or 
comes on during hot summer weather. It seldom runs as high 
as does the aconite or veratrum fever. The tongue may be 
coated yellow or thinly covered with mucus, and the taste is flat 
and pasty. 

Arsenicum all), will be of use in prolonged cases, and when 
there is great prostration. 

Belladonna may be occasionally indicated for the cerebral 
symptoms. 

For further therapeutic indications I will refer you to the 
treatment of intermittent and typho-malarial fevers. 



Malarial Fevers. 

With this digression we will proceed to the consideration 
of the malarial or miasmatic fevers — the first in order of 
classification. The many varieties of this class of fevers have 
a common origin in a morbific agent, which has, by gen- 



36 LECTUKES ON FEVERS. 

eral consent, received the name of miasm. They present many 
symptoms and conditions which serve to outline the class, 
and yet are attended by phenomena so widely different in char- 
acter as to necessitate their being regarded as distinct diseases. 
The severity and type of fever are determined, other things be- 
ing equal, by the amount of miasm operating at any given time, 
and the presence or absence of conditions favoring its develop- 
ment. The more intense and concentrated the malarial poison, 
and the more prolonged the exposure to its influence, the more 
rapid will be the development, and the greater the extent of the 
morbid processes. Arranged in a progressive scale, marked by 
the quantity and intensity of the miasm, we may begin with the 
quartan intermittent, and ascend to the tertian; go still higher 
to the double tertian and the remittent, and at last reach the per- 
nicious. The more severe types are apt to be encountered in the 
tropics, and the lighter prevail the farther we recede from the 
equator. 

Malarial diseases are usually endemic in character. At times 
they are epidemic, and when so prevalent, appear to stand in some 
hitherto inexplicable relation to epidemics of other diseases. 
According to Hertz the first recorded malarial epidemic pre- 
vailed in 1558, and spread over the whole of Europe. It was 
preceded by the influenza epidemic of 1557, and followed by the 
plague from 1559 to 1563. The second malarial pandemic occur- 
red in 1678 and 1679, and was followed by the plague, which 
lasted for three years. The third epidemic appeared during the 
four years following 1718, and was succeeded by a general out- 
break of typhoid fever. The fourth prevailed from 1807 to 1812. 
It was preceded by influenza and followed by typhoid fever. 
And the epidemics of 1824 and 1845 were each the forerunner of 
a typhoid epidemic. 

Influenza and malarial diseases seldom prevail simultaneously. 
The same may be said, though in a less general sense, of typhoid 
fever and malaria. On the other hand, epidemics and endemics 
of remittent and typhus are -frequently met with at the same 
time. Cholera and malaria often flourish side by side, while 
intermittent fever and dysentery are well-known associates. 
Miliary tuberculosis too, frequently exists alongside of inter- 
mittent fever in malarial districts. The presence of malaria is 
now generally believed to favor and predispose to phthisical de- 



GEOGRAPHICAL LIMITS. 37 

■velopment. And it is a clinical fact that in extensive endemics 
of intermittent fever, other diseases are apt to present the typ- 
ical features, exacerbation and remission. 

Geographical Limits. — Malaria may prevail anywhere be- 
tween 63 c north latitude and 57 ° south latitude, but is more in- 
tense the nearer the approach to the equator. It is seldom gen- 
erated above an elevation of 1,000 feet above sea level. To this 
rule, however, there are exceptions. For malaria has been found 
in Peru, at an altitude of 10,000 feet, and in the plateaus of the 
Pyrenees at 5,000 feet, as well as in lesser elevations. Italy is 
undoubtedly the most malarious of all European countries. The 
Pontine marshes are proverbial as being vast hotbeds of malaria. 
In Africa the most virulent forms of malarial diseases appear on 
the western coast and along the banks of the Kiger and Senegal 
rivers. The delta of the Ganges is the most malarious region 
in all Asia. And on this continent the Gulf states, the western 
coast of Peru, and the interior of Brazil furnish the most malig- 
nant forms of malarial diseases. 

Marshes are especially favorable to the development of mala- 
ria, and yet all marshes are not malaria producing. Such as 
have a clay or limestone bottom develop the poison more read- 
ily than those possessing a sandy substratum. Dried up marshes 
develop it more rapidly than the submerged. Heavy rains 
cover up the marshes, and, although they favor a luxurious veg- 
etation, protect them from the influence of the sun's rays. After 
the rains have ceased and the marshes begin to dry up, the heat 
of the sun causes vegetable decomposition to take place, and im- 
mediately all the conditions favorable to the development of 
malaria are presented. Hence malarial diseases prevail more 
extensively during hot weather following heavy rains, than at 
any other time. Some marshes are always fecund with malaria. 
"Witness the Pontine marshes which have been malarial for over 
2,000 years. On the other hand there are extensive swampy 
regions in hot climates that are entirely free from malarial 
fevers. Among these may be mentioned the warm swamp re- 
gions of the Australian coast, and the shores of the lake of Tes- 
cudo, in Mexico. Low lands that are exposed to annual over- 
flow, such as are found along the southern shores of the Missis- 
sippi, are as fruitful of malaria as the swampy regions. Salt 
water marshes are as a rale free from malaria. But a mixture 



38 LECTUEES ON FEVERS. 

of salt and fresh water, as on the New Jersey flats, is specially 
favorable to its development. Malarial soils, though oftenest 
found in swampy regions, are frequently discovered in localities 
which are not, and never have been, swampy. In new and unset- 
tled districts the upheaval of the alluvial soils favors the devel- 
opment of malaria. 

Edwards rationally explains this by saying that "all land — 
all soil that has never been before worked, — is particularly rich 
in organic matter. The leaves from the trees have for centuries 
been dying, decomposing and yielding their organic constituents 
to this earth. The birds and wild animals which, from the be- 
ginning of time, have roamed over this virgin land, have depos- 
ited their organic excrement upon it. The winds have wafted 
organic material from far off cities to it; while countless myriads 
of animals have died and decomposed on this land, yielding up 
their component parts to it. The rains and snows of centuries 
have washed all this organic material into the earth, until this 
land fairly teems with organic wealth. Like the untrodden prai- 
ries of our western country it is black with organic richness. 
Some little of this material is utilized in giving nourishment to the 
grass and trees which grow on this soil. Still, but a very small 
proportion of this organic matter is thus consumed, and what 
little is used is returned a hundred-fold in the manner indicated 
above, until the sub-soil of this region is fairly reeking with or- 
ganic elements not exposed to the sun, while that very near the 
surface is consumed by the grass and trees. This soil contains 
moisture. Man and civilization come along; the plough turns 
up this land; this enormous accumulation of organic matter is 
exposed to the sun. 

"What have we? Organic matter, heat and moisture." The 
three conditions which we will soon find are the most favorable 
to the developments of malaria. At this date malarial diseases 
are spreading eastward and northward in the New England states. 
Just why this should be so we are unable to say. The state 
authorities are busily engaged trying to solve the problem. 

The Nature of Miasm. — Up to the present time but little 
is known of the exact nature of malarial poison. Many theories 
have been advanced concerning it, since the dawning of the 
present century. Some of the older observers believed that it 
was the result of the decomposition of vegetable organisms, and 



BACILLUS MALARIA. 39 

existed in a gaseous form. Others attributed it to subterranean 
exhalations. A few declared it to be a specific poison having 
no tangible chemical or microscopical constituents. Some be- 
lieved it to be of a vegetable nature, while others contended with 
Armand, that the thermo and electro-hygrometric phenomena 
of the atmosphere constituted the remote causes of fever. These 
conjectures all remain unproven, and we are as yet in doubt 
concerning the nature and working of the malarial poison. 

The theory that is now attracting the most attention, and 
which thus far appears the most rational, is that which attrib- 
utes all malarial diseases to the presence and germination of a 
special fungus, the bacillus malarise (Fig. 4), in the blood. The 
recent experiments of Klebs and Tommassi-Crudeli of Borne, 
following those of Scoda, Balestra, Salisbury, and Hannon, have 
done much to turn the tide of professional opinion in favor of 
the parasitic theory. The former experimenters claim to have 
discovered to a certainty the presence of the bacillus malarine 
in the soil and atmosphere of malarial districts, and also in the 
blood of malarial fever patients. The "Medical Times and 
Gazette" in publishing an abstract of their report says: They 
first succeeded in producing the symptoms of malarial poisoning 
in animals by injection of watery extracts from the marshy soil. 
They then proceeded, by the process called "fractional cultiva- 
tion," to isolate the active material, that is the true generator 
of the disease, supposed to be a living organism. Lastly they 
isolated the organisms by filtration, and comparing the results 
obtained in injections of the filtrate with those produced by the 
residue containing the organisms, they proved that the poison of 
malaria resides in these. The fungi obtained appeared as small 
rods of 0.002 to 0.007 millimeter in length, growing into long 
twisted threads. The fungus is markedly aerobiotic. If air is 
excluded, it dies out. The injection of these fungi, true bacilli 
malariae, into the healthy animals always gives rise to symptoms 
of intermittent fever, with enlargement of the spleen, etc. Later, 
Cuboni and Marchiaf ava at Borne, have been able to demonstrate 
spores and bacilli in the spleen, the marrow, and blood of three 
persons who died of pernicious fever, showing the same charac- 
ters as those observed by Klebs and Crudeli. Dr. Sternberg's 
experiments with swamp mud taken from the suburbs of New 
Orleans fully corroborate those of the Italian physicians. 



40 LECTUEES ON FEVEES. 

Important observations have still more recently been made by 
Laveran and Bichard in France. The former noticed a peculiar, 
though differently formed, organism possessing very remarkable 
characters, invariably present in the blood of malarial fever 
patients ; while the latter found the special habitat of the 
parasite to be the red corpuscles of the blood. Richard's obser- 
vations on the life history of the organism are thus reported: 
" During the attack of fever many blood globules are seen 
which possess a small, perfectly round spot, but they have other- 
wise the normal appearance and possess the normal elasticity. 
In other corpuscles the evolution of the parasite is further 
advanced; the clear spot is enlarged and is encircled by small 
black granules, while around it the haemoglobin, recognizable by 
its greenish-yellow tint, forms a ring which becomes narrower as 
the parasite increases in size. Ultimately this substance of the 
corpuscle is reduced to a narrow, decolorized zone, from which 
the haemoglobin has disappeared. The appearance is then that 
of a circular element, having nearly the dimensions of a red 
blood globule, and containing an elegant ' collarette ' of black 
granulations, which is in effect the organism arrived at maturity. 
The parasite then pierces the membrane which contains it, and 
escapes into the blood plasma. In the ultimate condition of 
many of the infected corpuscles the pigmentary collarette is 
absent, and there is merely a greyish mass, containing a few 
black granulations, which have been noted by Kelsch, and some 
other observers. These pigment-granules become free, and 
rapidly broken up by the leucocytes, which become impregnated 
with them. Hence the melanotic leucocyte, which has often been 
observed in malaria is, so to speak, only an epi-phenomenon of 
the palustral process, the primordial and essential change being 
that in the red corpuscles." But it is impossible liere to enter 
into a more lengthy consideration of the facts and arguments by 
which this parasitic view has been supported. Suffice it to say 
that from the evidence already at our command the bacteria 
theory may be considered as placed on something like a sub- 
stantial basis. 

The Laws of Malaria. — In all malarial localities, three impor- 
tant factors are invariably necessary for the multiplication of 
the parasite, and development of the morbific agent: 

1. A certain amount of vegetable matter. 



IMMUNITY FEOM MALARIA. 41 

2. A certain amount of moisture. 

3. A certain average degree of temperature. 

The vegetable matter and the moisture must be found either 
on the surface, or in the substance of the soil. And the average 
temperature for the twenty-four hours must not fall below 58° 
Fahr. A prolific germination, and consequent rapid increase 
of malaria, will not take place unless the average daily tempera- 
ture ranges as high as 68° Fahr. 

Malaria may find entrance into the human organism in either 
of two ways: 

1. By the respired air. 

2. By the intestinal tract, with food or water. 

Once introduced into the body, it has the power to reproduce 
itself. The length of time that elapses between the introduction 
of the morbific agent and the outbreak of the malarial attack 
varies from six to twenty days. This period is called the stage 
of incubation, and has an average length of fourteen days. 

No race or nationality enjoys immunity from malaria. But 
according to statistics*, the blacks are less susceptible than the 
whites. All periods of life from infancy to old age are liable 
to its attacks. In children under five years it commonly as- 
sumes the form of intermittent bowel troubles. In youth, inter- 
mittent and remittent fevers are the most prevalent. In adult 
life, malaria may appear in all its forms. And in old age, the 
attacks though less common, are apt to take on the pernicious 
type. Women are more susceptible than men. The masked 
forms of intermittents occur more among the former, while the 
severer forms of malarial diseases are oftener met wuth among the 
latter. Women are oftenest attacked at the time of menstrua- 
tion, but are said to enjoy immunity during the last months of 
pregnancy. Idiosyncrasies of constitution render some less lia- 
ble than others to its influence. The weak and the anaemic are 
easy victims; and an organism once invaded is thereby ren- 
dered more liable to subsequent attacks. It is very doubtful 
wdiether an organism which has once been thoroughly charged 
with malaria, can ever become entirely free from its influence. 
A certain degree of tolerance of malaria — called by some ac- 
climation — may come from long residence in a malarial district. 
This tolerance must not however be construed an exemption 
from its influence. And although it is the new comers to a ma- 



42 LECTUEES ON FEVERS. 

larial district who suffer the most from the acute manifestations,, 
yet the older residents are apt to enjoy less robust health in 
consequence of some chronic malarial affection. Should one of 
the latter, old and apparently acclimated settlers, be taken sick 
with any active form of disease — pneumonia for example — he 
would be almost sure to succumb, owing to the surcharge of the 
system with malarial poison, when under other circumstances he 
would in all probability have recovered. 

Malaria is peculiarly endemic, and seldom wanders far from 
its native soil. It may however be carried down rivers from 
malaria-generating to non-generating regions; and it may also 
be carried by the wind from malaria producing to non-malarial 
districts. From four to five miles is the greatest distance it 
has been known to be transmitted by the wind. It may be 
carried by the latter up along the sides of mountains to an eleva- 
tion of from 500 to 1,000 feet. 

Conditions FavoraMe to the Development of Malaria.— 

The three conditions necessary to the development of miasm 
are: 

1. A luxurious vegetation, with partial decomposition. 

2. A temperature above 58° Fahr. The higher the temper- 
ature, the more virulent the miasm. 

3. Moisture and atmospheric air. 

As aiding or supplying these conditions, we will mention the 
following: 

1. Marshes, swamp lands and damp bottom lands. These are 
especially active after heavy rains, when they are drying up, or 
are simply covered with a thin sheet of water. 

2. A mixture of salt and fresh water marshes furnishes the 
most favorable conditions for the development of malaria. 

3. Railroad excavations, and the cultivation of new lands, 
favor the generation of miasm by bringing decomposed vege- 
table matters to the surface, and by exposing the new soil to the 
heat of the sun and moisture. 

The excavations necessary for the laying of the cable track of 
the south side street railway, and for the patting down of sew- 
ers in this city, are at the present time causing the generation of 
malaria, as evidenced by the increase of malarial diseases along 
the lines of excavation. 

4 Hertz speaks of the favorable conditions for the develop- 



DEVELOPMENT OF MALARIA. 43 

ment of malaria presented by an elevated and apparently dry 
region, with a stratum of loose surface soil and a deeper 
floor of clay or some other impermeable soil beneath, where a 
large amount of surface water loaded with vegetable ingredients 
percolates through the loose upper earth and is retained in the 
lower stratum. The intense heat of the sun often causes cracks 
and deep rifts in the earth, and by exposing the vegetable mat- 
ters to decomposition favors the germination of the miasm. 

5. The wind exerts considerable influence in developing as 
well as in conveying malaria. This may depend somewhat upon 
various thermo-atmospheric conditions. 

6. All weakening influences such as increased moisture of the 
atmosphere, exposure to excessive solar heat, sudden cooling of 
the cutaneous surface, and inordinate eating or drinking, favor 
the action of malaria. These, each and all, act by disturbing 
the equilibrium of the body, and thus diminishing the power of 
resistance. 

Conditions Inimical to the Production of Malaria.— Pass- 
ing from this enumeration of the favorable conditions, we will 
now briefly consider the unfavorable ones: 

1. We may mention the extremes of latitude. Malaria is sel- 
dom generated north of 63° north latitude, or south of 57° south 
latitude. The farther, we recede from the equator, within these 
limits, the more feeble becomes the malarial poison. 

2. Malaria is seldom generated beyond 1,000 feet above the 
level of the sea. 

3. Thorough ditching and draining, with steady cultivation of 
the soil, prevents any prolonged generation of malaria in the' 
majority of marshes. 

4. An average temperature below 60° Pahr., is always unfa- 
vorable to the generation of the malarial poison. This is a gen- 
eral rule, and holds good everywhere. 

5. The daytime is less favorable for the development and ger- 
mination of the miasm than is the night. 

6. Strong winds diminish the virulence of the poison. On the 
other hand a hot and dry atmosphere with little or no wind,, 
especially after heavy rains, increases it. 

7. Certain plants are found to lessen the quantity of malaria. 
The common sunflower (Helianthus Annuus), possesses consid- 
erable absorbing power, and has been used with great success in 



44 LECTURES ON FEVEES. 

the Eastern states. The Calamus (acorns calamus aromaticus) 
has been used, and is recommended by Sebastian. And the 
Eucalyptus has been planted with some success throughout the 
marshes of Italy. 

8. At times, all the conditions exist that are necessary to gener- 
ate miasm, and yet no poison can be found. This peculiar 
phenomenon is believed to be caused by the presence of ozone, 
which is largely developed in some marshes, and exerts, as you 
know, a paralyzing influence over bacterial life. Examples of 
this may be found among the islands of the Pacific, and in the 
swamp lands of Australia. 

Climatic Influences in the Genesis of Malaria. — The sea- 
sons of the year have considerable influence over the develop- 
ment of malaria. In tropical regions malarial fevers almost 
always arise during the summer. They begin about the latter 
part of June or the first of August, and they reach their acme 
sometime between July and October. In colder climates they 
appear in the spring, decline in the summer, and re-appear in 
a more serious form in the fall. In temperate climates the win- 
ters are usually free from malarial diseases. In the tropics the 
more damp the year the more severe the fevers. A wet spring 
and a hot summer followed by a hot autumn, as well as a wet 
spring and hot summer followed by a wet autumn, give a decided 
impetus to the development of malaria. During the summer 
there is a tendency to implication of the nervous system and di- 
gestive apparatus, while during the winter the disposition is to 
catarrhal and inflammatory affections of the respiratory organs. 
The quotidian type of intermittents occurs oftenest during the 
warm summer months. The tertian appears mostly in autumn 
and early spring. Remittents tend to follow the quotidians, 
and quartans are apt to follow tertians in the autumn. 

Critical Bays. — Favorable cases of fever show a decided tend- 
ency to terminate upon what are called critical days. The crit- 
ical days are the 3d, 5th, 7th, 9th, 11th, 14th, 17th, 21st, 27th 
and 31st. The non-critical are the intermediate clays; but the 
4th and 6th are considered secondarily critical. A seven days' 
case of fever usually terminates on the 3d, 5th or 9th day, and 
a fourteen days' case on the 3d, 5th, 7th or 9th. Cases that pass 
the 7th clay are apt to go on to the 11th. The fourth clay of the 
w r eek is always the indicative clay. Hippocrates says that sweats 



CRITICAL DAYS. 45 

occurring on critical days are salutary, and denote a favorable 
turn in the disease, while those which occur on the other days 
denote exhaustion, obstinacy and relapse of the disease. My 
friend Dr. Raue, following Grauvogl, thus explains the doctrine 
of critical days : 

According to physiological experiments it appears that a liv- 
ing organism, when it is subjected to a starving process, does 
not lose its bodily substance evenly, but rather periodically, so 
that its greatest losses always fall upon the fifth, eighth and 
thirteenth days. Thus the operations in a living organism differ 
essentially from mere mechanical or chemical operations. If you, 
for example, expose a vessel with water to an equally dry atmos- 
phere, it will lose its contents by evaporation evenly, just so 
much an hour. The living organism does not. It regulates its 
expenditures or its losses according to its own laws, which allow 
its receipts and expenditures to oscillate between a certain bound- 
ary, and make its operations to go on in regular periods. 

These periodical fluctuations are therefore the law of normal 
life, part and portion of all its evolutions in health and disease, 
and are not peculiar to states of disease. "When, therefore, in 
diseases on the third, fifth, seventh, thirteenth, twenty-first and 
thirty-fifth day, a greater amount of losses sets in, in the form 
of excretions, such as sweat, flow of urine, diarrhea, etc., which 
is called the crisis, it is nothing more or less than the same peri- 
odic oscillation which is going on continually in the living organ- 
ism, and which becomes more conspicuous only in disease, be- 
cause it is frequently followed by a decided improvement or 
death. It necessarily must become more conspicuous, because 
this periodical loss is added to the extra consumption, which is 
a condition of the acute disease. If the physical state of the pa- 
tient be such as to endure both, he, of course, must feel better 
the next day, when the periodical acme ceases; and he dies, if 
his physical power cannot endure the united action of both. 
Thus the critical days of the disease are nothing more nor 
less than the normal, periodical fluctuations of the living organ- 
ism, with which they correspond; and the crisis is that critical 
day with its normally increased excretions, which falls together 
with the height of the disease. 

These observations are corroborated by the following facts: 
that the so-called crisis does not appear, when during the course 



46 LECTURES ON FEVERS. 

of a disease the organism is weakened by improper medication, 
because then the natural periodic fluctuation is disturbed and 
destroyed; and it does not appear when, by the application of the 
proper remedy, health is restored; because the periodic fluctua- 
tion alone is not conspicuous enough to be observed. It is, how- 
ever, never wanting when the disease runs an undisturbed 
course; and in so far it is an important means to distinguish 
between a successful and an unsuccessful treatment. 
Eaue further says, that: 

1. The right remedy cures a disease without a crisis; and 
thus we have an indisputable proof that the selected remedy 
was the remedy. 

2. Aggravations after a remedy, when they occur on critical 
days, need not be the result of the remedy, as the conjoined 
action of the disease and the periodical oscillation alone, will 
cause them naturally. 

3. When after the administration of a homoeopathic remedy 
a crisis takes place notwithstanding, we may be sure we did not 
"hit " the case, and that the patient got well without our aid. 

4 When no crisis appears, and the patient gets worse and 
worse, it is clear that we did not find the right remedy, and we 
may even have spoiled the case by wrong means. 

Thermometry of Fevers. — A few words on the temperature 
range in fevers and I have done. You all well know that the 
normal temperature in the axilla is stereotyped at 98.6° Fahr., 
and that it is about a degree higher in tropical than in temper- 
ate climates. In temperate regions it is highest in the early 
morning and lowest at midnight, while in the tropics it is lowest 
in the early morning and highest during the day. In children 
it may be normally one or two degrees higher than in adults. A 
temperature rise of 1° Fahr. corresponds, as a rule, with an 
increase of from 8 to 10 beats per minute, of the pulse. In 
severe diseases the temperature may fluctuate between 95° Fahr. 
and 109° Fahr. The highest temperatures are found in scarlet 
fever and yellow fever. Wunderlich, who has made a special 
study of clinical thermometry, gives us the following charac- 
teristics: Temperatures much below 96.8° Fahr. are collapse tem- 
peratures; below 92.13° Fahr., deep, fatal algid collapse; 92.3° 
to 95° Fahr., algid collapse, with great danger, still with possi- 
bility of recovery; 95° to 96.8° Fahr., moderate collapse, in itself 



TEMPERATURES. 47 

without danger; 99.5° to 100.4° Fahr., sub-febrile temperature; 
100.4° to 101.12° Fahr. slight febrile action; 101.3° to 102.2° 
Fahr. in the morning, rising to 103.1° Fahr. in the evening, 
moderate fever; 103.1° Fahr. in the morning and about 104° 
Fahr. in the evening, considerable fever; 103.1° Fahr. in the 
morning and above 104.9° Fahr. in the evening, high fever; 
107.6° Fahr. and above indicates usually a fatal termination, ex- 
cept in relapsing fever. Temperatures have occasionally been 
reported as high as 112°, 113°, 115° and even 117° Fahr., where 
patients have recovered. 

A fever temperature of 104° to 105° Fahr. indicates that the 
progress of a disease remains unchecked. 

A rise in temperature or a stable high temperature from 
evening until morning is generally a sign that the patient is get- 
ting, or will get, worse. But stability of temperature from morn- 
ing to evening is generally a favorable indication. All temper- 
atures should invariably be taken morning and evening, and still 
more frequently in critical cases. The axilla is generally con- 
sidered as the best place to take the temperature, though in chil- 
dren the rectum is probably better. And from three to five 
minutes is the average interval between the insertion and re- 
moval of the clinical thermometer. 



LECTUEE III 

Simple Intermittent Fever. 

At my last lecture I spoke of the nature and origin of malarial 
poison. To-day I wish to direct your attention to the fevers 
caused by this poison. The first in the list, according to our 
classification, is Simple Intermittent Fever. 

Definition. — Simple intermittent fever may be defined as a 
paroxysmal disease, due to the action of malarial poison, and 
characterized by the occurrence of febrile paroxysms ( consist- 
ing usually of a succession of definite stages, viz. the cold, the 
hot and the sweating stage), separated by intermissions or apy- 
rexial periods of variable length. According to the length of 
the interval, the fever may be of different types, viz . quotidian, 
tertian or quartan. 

Synonyms. — It is popularly known as ague, fever and ague, 
chills and fever, the shakes, swamp fever, etc. 

History. — The history of intermittent fever dates from early 
times. Celsus clearly defined the quotidian, tertian and quartan 
forms. Archigenes first recognized the masked intermittents, 
and Diomedes Cornarus was the first writer who described an 
intermittent type of dysentery. Later Rhazes described those 
long-lasting types of intermittents, having no apyrexial period, 
where the chill stage of a second paroxysm occurs during the 
sweat stage of the first, and which constitute a transition stage 
to the remittent. Intermittent fever is recorded as having been 
quite fatal in Europe during the seventeenth century. In the 
early part of the present century it prevailed very extensively 
throughout this country, and was alarmingly fatal. . 



CLINICAL HISTORY. 49 

Etiology. — Intermittent fever is universally conceded to be 
due to malarial poisoning. The nature of the poison has been 
already considered in a previous lecture. We will therefore 
pass by the question of causation, simply reminding you of the 
fact, that the preponderance of testimony from recent investiga- 
tions tends to strengthen the theory of the parasitic origin of 
the intermittents, and points to the bacillus malarias as the 
cause. 

Clinical History. — The clinical history embraces a descrip- 
tion of the prodromal stage, the three paroxysmal stages, the 
intermission, the types, and the sequelae. The prodromal stage, 
or the stage of incubation, is of variable length, averaging from 
six to eight days. This stage is not always present, for fre- 
quently, suddenly and without warning, the paroxysmal stage is 
ushered in. The symptoms are uniformly not very definite. 
The patient feels tired, and complains of frontal headache, pains 
in the loins and legs, with yawning, stretching, and general 
malaise; the functions of the stomach are somewhat impaired, 
and there is thirst and anorexia. The taste is metallic, the breath 
foul, and the tongue furred, yellow in the center and white at 
the edges; the skin is hot, dry, and perhaps slightly icteric; the 
pulse is small and frequent; the urine is scanty, high-colored, 
and deposits a red sediment; the fecal discharges are dark-colored 
and offensive; these symptoms continue with more or less prom- 
inence from one to ten days, and eventually terminate in a 
rigor, which is the commencement of that series of phenomena 
which characterize the paroxysmal stage. 

Paroxysms. — A paroxysm of intermittent fever consists of 
three well-marked stages, viz: the cold, the hot and the sweating 
stage. 

Cold Stage or Chill. — This stage is usually ushered in by a 
sensation of chilliness or coldness beginning in the back, loins 
or extremities, and gradually creeping over the entire body. 
The skin becomes pale and shrunken, and presents the appear- 
ance of goose-flesh (cutis anserina. ) The face becomes pale, 
the eyes are sunken, the nose is pointed, and the lips and finger- 
ends become blue; the sensation of chilliness increases, the 
teeth begin to chatter, the limbs commence to shake, and the 
whole frame participates in the general commotion; the voice 



50 LECTUEES ON FEYEES. 

becomes weak, husky, and tremulous; the respiration becomes 
hurried, and is attended by a sense of weight and tightness in 
the chest, and not unfrequently by a short, dry cough; the pulse 
is small, quick, and firm; the mind is usually clear, but pecul- 
iarly irritable; occasionally there is delirium; in young children, 
convulsions are apt to occur; the temperature of the surface of 
the body is below the natural standard, while in the mouth, 
axilla or rectum the thermometer may register 104° Fahr., or 
105° Fahr; the mouth is dry, but the tongue continues moist; 
thirst is usually urgent, and nausea is often a prominent symp- 
tom; the urine is increased in quantity, clear, colorless, of low 
specific gravity, ami does not deposit a sediment on cooling; the 
dejections are apt to be dark and bilious; this stage lasts from a 
quarter of an hour to three hours. Its departure, which is some- 
times abrupt but generally gradual, is announced by the abate- 
ment of the chills, and by the appearance of transient flashes of 
heat, starting from the extremities. 

Hot Stage. — This stage is one of reaction. The countenance 
is no longer pale and shrunken, but on the contrary it is flushed 
and turgid; the heat of the surf ace now becomes marked; the 
temperature rises to 105° Fahr., and at times approaches 110° 
Fahr., or even higher; the pulse is full, strong and rapid; the 
respirations are hurried, but not oppressed; the headache in- 
creases and the patient becomes extremely restless ; the mouth 
is dry and hot, the tongue parched, and herpetic vesicles occa- 
sionally appear on the lips; thirst is a prominent and distressing 
symptom; the urine is now scanty, high colored, and of high 
specific gravity; this stage may last from an hour or two to 
twelve or sixteen hours. The average duration is from three to 
four hours. 

Sweating Stage. — This stage comes on gradually. It com- 
mences in a perspiration which appears first on the forehead 
and face, and afterward on the trunk and extremities ; the pulse 
now loses its frequency; the breathing becomes natural; the 
urine passes freely, but retains its high color, and deposits a 
light red, lateritious sediment; the headache and thirst abate; 
the fever disappears. The patient falls off into a quiet sleep, 
and the state of apyrexia is established; the average duration of 
this stage is from three to four hours. 

Such is the normal course of an intermittent paroxysm. Devi- 



LAWS OF PAROXYSM. 51 

ations may however occur, and certain stages may at times be 
wanting. 

Dumb ague is the popular name for an attack from which the 
chill is absent, the fever and sweat alone recurring periodic- 
ally. When an intermittent paroxysm occurs one day, and an 
intense neuralgia, urticaria, dyspepsia or dysentery takes its 
place the following day, we have what is termed a masked inter- 
mittent. 

Intermittent neuralgia — very common in malarial districts — 
may attack either the intercostal, the sciatic, or the frontal branch 
of the ophthalmic division of the fifth nerve. When it attacks 
the latter nerve it is called "brow ague." In malarial districts 
all complaints are apt to take on periodicity. 

Intermission. — During the intermission the patient may at 
first feel ordinarily well. But after repeated paroxysms, he is 
apt to become debilitated and anaemic, and sooner or later pre- 
sents all the symptoms of malarial cachexia. 

Laws of the Paroxysm. — The following laws have been tab- 
ulated as governing to a certain extent the paroxysm : 

1. The shorter the intermission the longer the paroxysm. 

2. The longer the paroxysm the earlier it commences in the 
day. 

3. The more durable the cold stage, the less durable the other 
stages. 

Types. — Intermittent fever is divided into types correspond- 
ing to the length of the interval. The interval is the period 
from the beginning of one to the beginning of the next parox- 
ysm, and differs from the intermission in that the latter is the 
space between the ending of one paroxysm and the beginning of 
the succeeding one. Each type, viz: the quotidian, the tertian 
and the quartan, observes a law of periodicity in the succession 
of paroxysms. In the quotidian type the paroxysm recurs every 
day. In the tertian it recurs every other day. And in the 
quartan it recurs on the first and fourth days. The quotidian 
and tertian forms are the most frequent; while the quartan 
variety is comparatively rare. The tertian type occurs most 
frequently in temperate climates, but in tropical regions the quo- 
tidian prevails. 

In this country these two types vary in frequency during dif- 



52 LECTUEES ON FEVERS. 

ferent seasons. Usually the tertian is supposed to be the most 
prevalent. But in the aggregate, according to Woodward, the 
quotidian appears to predominate. For out of 98,237 cases oc- 
curring in the United States army, 51,623 were cases of quotid- 
ian fever, and only 44,857 cases were of the tertian variety. The 
quartan type occurs chiefly in autumn, but even then is rarely 
met with, excej)t during prolonged malarial attacks. The quo- 
tidian and tertian types prove more obstinate in autumn than 
at any other season of the year. The latter variety occurs more 
frequently in adults than in children, and attacks the sanguine- 
ous temperament oftener than the leucophlegmatic. In the quo- 
tidian type the paroxysm usually recurs in the morning (daily), 
and lasts from 8 to 10 hours. In the tertian it recurs about noon 
(of the third day), and lasts from 6 to 8 hours. While in the 
quartan it recurs in the afternoon or evening (of the fourth 
day), and lasts from 4 to 6 hours. 

Other types are mentioned by various writers, such as the 
quintan, in which the paroxysm recurs on the fifth day; the sex- 
tan on the sixth; the septan on the seventh; the odan on the 
eighth, and so on. Such cases are however great rarities, and 
are looked upon as simply curiosities of clinical experience. In 
addition to these simple types we have mentioned, irregular 
compound forms are occasionally encountered. Thus a double 
quotidian may be presented with two paroxysms daily: one severe 
in the morning, and the other mild in the afternoon or evening. 
Or a double tertian with a paroxysm daily; the paroxysms dif- 
fering on successive days, but corresponding in every respect on 
alternate days. Or finally a double quartan may- appear in 
which a paroxysm recurs on two successive days, but is absent 
on the third day. The double tertian is the most frequent of the 
compound types. 

As regards the regularity of its appearance, a paroxysm may 
be either anticipating or postponing. When it recurs a little 
earlier each day it is called an anticipating paroxysm. And it 
is called a postponing paroxysm when it recurs a little later each 
time. An anticipating paroxysm shows that the disease is pro- 
gressing, and is not being controlled by remedies, while a 
postponing paroxysm indicates that the disease is not only be- 
ing controlled, but is about to end. When a relapse occurs it is 
usually at the end of seven, fourteen, twenty-one or twenty- 



ANALYSIS OF CHART. 



53 



•eight clays from the last paroxysm. Patients cannot be con- 
sidered beyond the clanger of a relapse until six or eight weeks 
have elapsed without an attack. 





CHAET II.— Simple Intermittent Fever 




Types : 


Quotidian; Tertian; Quartan; Double Tertian. 


Period?: 


Incubation, 


Paroxysmal Period. 


Intermission. 


Cold stage, 


Hot stage, 


Sweating- 
stage. 


Duration:! 6 to 8 days, 


\i hr. to 3 hrs. 


3 to f hours, 


Uncertain. 

average. 
3 to i hours. 


ti hours 

to 
3 days. 


Initial 
Symptoms 


General 
malaise. 


Creeping- 
chills, starting 
in back, 


Hot flashes 

from 
extremities, 


Perspiration 
on forehead. 


1. 

X 

EH 

> 

X 

< 

Z 

V; 

X 


Tempera- 
t u re : 


May or may 

not be slightly 

above the 

normal, 


100° F. to 
105° F. 


105 c F. to 
110° F. 


Rapidly 

approaches 
the normal. 


Pulse: 


Small and 
frequent, 

so to 100 
per minute. 


Small, quick 

and ha I'd, 

90 to 120 

per minute. 


Full, strong- 

and rapid, 

110 to 140 per 

minute. 


Xcaily normal 

but weak. 

TO to 85 per 

minute, 


Respira- 
tion: 


Normal, 


Hurried and 

oppressed. 


Hurried but 
not oppressed. 


Normal, 


Skin: 


Dry. 


Cold. Faee 
pale and 
shrunken. 


Hot. Face 
flushed. 


Moist. 


Urine: 


Scanty and 
high colored, 


Profuse and 
colorless. 
low sp. gr. 


Scanty. 

high colored, 

high sp. gr.. 

dep. of urates, 


Copious 

but 

high colored. 


Tongue: 


Furred, yellow 

in center 

and white at 

edges, 

metallic taste, 


Moist 

and furred. 

Thirst. 


Parched 

with 
thirst. 


Moist. 


Intestinal 
Canal: 


Anorexia. 
Dark fecal 
discharges, 


Nausea and vomiting. 
Bilious dejections. 




Nervous 

system : 


Frontal 
headache, 


Headache, 
mind clear, 
but irritable, 


Increased 
headache, 

extreme 
restlessness. 


Duration : 


Duration of the disease is indefinite. 


j Sequels: 


Anaemia, Enlargement of Spleen C ague-cake"), Anasarca and dropsv. 


Etiology: 


Malarial poisoning. Bacillus Malaria?. 



ANALYSIS OF CHAET. 



The Nerrous System.— A chill more or less severe usually 
marks the onset of the attack; headache is very common and 



54 LECTURES ON FEVERS. 

occurs as an early symptom, it is usually frontal, but occasion- 
ally it becomes general; delirium is rare, and when it exists is 
but transitory; restlessness is frequently quite marked during 
the paroxysmal stage. Hyperesthesia of the cutaneous surface 
in the region of the first dorsal vertebra, is frequently associated 
with pain in the back of the neck. 

Tlie Temperature. — The temperature rises with great rapid- 
ity. During the initial chill it is often as high as 104 ° Fahr., 
and may reach 105 ° Fahr. or even 110 ° Fahr. in the hot stage. 
The defervescence is frequently as sudden and marked as the 
temperature rise. During the intermission the temperature is 
normal. 

The Circulation. — The pulse is variable. It is increased in 
frequency especially during the paroxysmal stage. At the period 
of highest temperature it is apt to be full and bounding. 

The Digestive System. — Nausea and vomiting sometimes 
accompany the initial chill. There is usually loss of appetite, 
thirst, impaired taste and a coated tongue; the evacuations are 
commonly offensive and of a dark color. 

The Secretions. — The urine is diminished in quantity during 
the incubative period and in the hot stage. Its color is darker 
than natural, except during the cold stage. The specific gravity 
is above normal in the hot stage, but below it in the stage of 
chill. The amount of urea excreted increases rapidly, reach- 
ing its maximum at the beginning of the hot stage. The cuta- 
neous surface is moist and cold during the chilly stage, but dry 
and hot during the hot stage. The perspiration during the 
sweat stage may be either copious or slight, and has a " fresh- 
baked brown bread " odor. A sallow or icteric hue generally 
attains in long lasting cases. Herpes labialis frequently appears. 

Sequels. — Anaemia is very apt to occur in cases of long dura- 
tion. And in protracted intermittents, as in those which have 
been marked by repeated relapses, a chronic malarial cachexia 
frequently obtains, characterized by sallow skin, anasarca and 
generally dropsy. While in still more severe cases, amyloid de- 
generation of the kidneys, liver or spleen may supervene. 

Morhid Anatomy. — Anatomically, simple intermittent fever 
presents no characteristic lesions other than those of hypergemia.. 



DIFFERENTIAL DIAGNOSIS. 55 

The blood, which is the vehicle of the poison, undergoes certain 
changes. A diminution in the number of red corpuscles and a 
decrease in the amount of fibrin invariably take place. The 

Fig. 9. 








Microscopical appearance of the blood in Malarial fevers, a. b. Bacillary 
filaments, c. Spore-products seen during cold stage of intermittent 
fever, d. Pigment granules. — N. B. — The red blood-discs 
furnish a scale for measurement. 

presence of black pigment granules (Fig. 9 ) has been fully 
demonstrated by Kelsch, Richard and others. And the bacillus 
malarias has been observed in the blood, liver and spleen, by 
Cuboni and Marchiafava. These changes in the composition 
of the blood are, however, not so well marked in intermittent, 
as in remittent and pernicious malarial fever. The spleen 
and liver are apt to become more or less enlarged from hyper- 
emia. The former organ especially, may become enormously 
enlarged, and distending the abdominal walls constitute what is 
vulgarly styled "ague-cake." 

Differential Diagnosis. — The differential diagnosis of simple 
intermittent fever is by no means difficult. A well marked case 
can hardly be mistaken for anything else. Latent and masked 
intermittents are perhaps more difficult of recognition. The 
only diseases with which it may be confounded are remittent 
fever, pyaemia and the hectic of tuberculosis. From remittent 
fever it may be readily distinguished by the fact that in remit- 
tent fever there is no intermission. This stage is always present 
in intermittent fever. The temperature during the remission 
in remittent fever is one or two degrees higher than normal; 
while in intermittent fever the temperature falls to the natural 



56 LECTURES ON FEVEES. 

standard during the intermission. Eemittent fever usually has 
but one chill, while in intermittent fever a chill inaugurates 
each paroxysm. From pyaemia it may be distinguished almost 
as readily as from the remittents. The accession of the fever in 
pyaemia observes no regularity, and there is no complete inter- 
mission. Whereas, in intermittent fever the febrile paroxysm 
comes on at regular intervals, and there is always a complete 
intermission. In pyaemia the chill is short, the fever runs high, 
and the sweating stage is generally prolonged. The temperature 
in pyaemia never approaches the normal, while in intermittent 
fever there is a period of complete defervescence. Febrile 
paroxysms resembling those of intermittent fever are occasion- 
ally noticed in connection with tubercular phthisis. In the hec- 
tic of tuberculosis the paroxysms occur oftener in the afternoon 
than in the forenoon, and the intermissions are incomplete. 
Whereas, the reverse obtains in true intermittent fever. The 
principal element in the diagnosis, however, is obtained by 
physical exploration. For in tuberculous disease the character- 
istic physical signs are seldom wanting. Finally, it should be 
remembered that paroxysms resembling those of intermittent 
fever are frequently produced by catheterism and other opera- 
tions on the urinary passages. 

Prognosis. — The prognosis in simple intermittent fever is as 
a rule, favorable. The tertians are the most easy of cure, while 
the quartans are the most obstinate ; the quotidians are the most 
serious in their results. The prognosis in masked intermittents 
is generally favorable. An anticipating paroxysm is an unfavor- 
able sign, while a postponing paroxysm is usually favorable. The 
presence of anaemia or dropsy vitiates the prognosis, as it in- 
dicates the development of malarial cachexia. Relapses are 
common. 



LECTURE IV. 

Simple Intermittent Fever.— (Continued.) 

TREATMENT. 

I will invite your attention to-day to the treatment of Simple 
Intermittent Fever. Many are the books that have been written 
on this subject and innumerable the writers who have tried to 
definitely outline its course. And yet our therapeutics can 
scarcely be declared the richer from these efforts. For, notwith- 
standing all that has been written, we have nothing better to 
offer you this morning than the advice given by Hahnemann 
long years ago, viz. : Let the totality of the symptoms be your 
chief guide in the selection of your remedy. To individualize 
each case closely is your only choice. As you watch the sequence 
of symptoms in your search for a remedy, two similars will gen- 
erally appear before you. The one general in character, and 
corresponding with the symptoms which are diagnostic of the 
disease; and the other special, and corresponding with peculiar 
symptoms which characterize each individual case. The latter 
is of more importance than the former in making the selection. 
Other things being equal the symptoms of the paroxysm are 
not of as much importance as those of the intermission. Look 
then to the intermission for the leading indications. Watch the 
concomitants of the case. And finally rely, whenever you can 
make the selection, on the single remedy which covers the symp- 
toms of both the paroxysm and the intermission, and is the special 
in the case. 

The best time to administer the remedy is during the inter- 
mission. In severe cases it may be continued into and through 

57 



58 LECTUEES ON FEVERS. 

the paroxysm. Beware of too frequent changes of the remedy.. 
For as long as the paroxysms continue to decline in duration and 
intensity, the patient is doing well and there is no necessity for 
a change. 

Touching the question of potency, let me advise you to be 
neither high nor low, exclusively. For the high attenuationist, 
on the one hand, is apt to lose sight of his patient, and the 
causation of the disease, in his desire for altitude; while the 
low attenuationist, on the other, who lives only in the lower 
stratum of the law of similars, fails to reap all the benefits capable 
of being derived from a more generous comprehension of its 
truths. The practice which has been the most successful in the 
treatment of intermittents is to use the lower attenuations in 
recent cases, and the higher attenuations in the chronic forms. 

Laws of Selection^ etc. — As tending to further guide you in 
the selection and administration of the remedy, we will formu- 
late the following laws: 

1. Individualize each case. 

2. Follow the totality of symptoms. 

3. Grade the symptoms. Give special prominence to those 
peculiar to the patient; select as next in importance those ap- 
pearing during the intermission; and supplement both with 
the symptoms of the paroxysm. 

4. Never change a remedy when the paroxysms are lessening 
in duration and intensity. 

5. In acute cases use the low attenuations; in chronic cases 
use higher attenuations. 

Prophylaxis. — Residents in malarial districts, should, as far 
as possible, avoid over-fatigue, exposure to sudden changes of 
temperature, dietetic errors, and excesses of all kinds. The 
sleeping apartments should be in the upper part of the house, 
so as to be above the stratum of malaria which is denser the 
nearer the approach to the earth's surface. Susceptible individ- 
uals should remain in-doors at night. When late evening and 
early morning exposures cannot be avoided, a respirator should 
be worn. At all times respiration should take place through the 
nostrils, and the mouth kept closed. The food should be nour- 
ishing and taken with regularity. All contaminated waters 



PRINCIPAL KEMEDIES. 59" 

should be boiled and filtered before used. And breakfast should 
always be taken before going out in the morning air. Flannel 
or silk should be worn next the skin. When malarial fevers are 
prevailing quinine 3x, gelsemium 3x, or alstonia constricta lx 
may be given morning and evening as a preventive. 

Principal Remedies. — Quinine. — Our sheet anchor in the 

treatment of simple intermittent fever is quinine, for no other 
remedy is so frequently the similimum for a case of ague. And 
so generally is it indicated, that there is room for doubt whether 
in intensely malarial districts intermittent fever can be arrested 
without its use. An additional reason for its frequent use exists 
in the fact that it has the power to destroy the bacillus malariaa 
in the blood. 

Truly it is a most potent aid in malarial diseases. And as the 
Master laid the foundations of homoeopathy in cinchona bark, 
we can ill afford to esteem it slightly. Our brethren of the old 
school have woefully abused it with their massive doses, For when 
quinine is adapted to a case it will cure it in small doses, and 
will cure it quickly. Large doses of the drug are apt to produce 
toxical effects and generally the patient is made worse instead of 
better. The severest type of malarial cachexia is often induced 
by over-dosing with quinine. Quinine is especially adapted to 
acute intermittents of the tertian type. The more perfect the 
intermission, the stronger is the indication. In chronic inter- 
mittents and in malarial cachexia it will seldom prove a remedy. 

The proper time to administer quinine is during the intermis- 
sion. You may give it in varied strength, from the second trit- 
uration to two-grain doses of the drug. And in occasionally 
severe forms of simple intermittent fever, such as may occur in 
intensely malarial regions, the hypodermatic injection of the bi- 
sulphate of quinine as recommended in pernicious malarial fe- 
ver, may render excellent service. It will sometimes happen to 
you in practice, that the picture of a case cannot be made to 
correspond closely with the picture of the nearest remedy, and 
that consequently the correct similimum cannot be reached. In 
such cases quinine may be given from one to three hours before 
the paroxysm, and the most nearly similar remedy during the 
fore part of the intermission. For time-honored experience has 
demonstrated, that when so administered, it curtails the parox- 



'60 LECTURES ON FEVERS. 

ysms, hastens the cure, and does not in any way interfere with 
the action of the chosen remedy. 

Arsenicum all), ranks next to quinine. It differs markedly 
from the latter in this, that the more widely the paroxysms vary 
from the typical form, the better it is indicated. Some of the 
stages of the paroxysm may be wanting. The fever stage may 
recur alone. There may be no preceding chill, nor following 
sweat, and the intermission may be oftentimes but poorly marked. 
Unusual functional derangement of the abdominal organs fre- 
quently appears in the arsenic cases. The prostration is gener- 
ally greatest after the hot stage. Arsenic is apt to be needed in 
imported, slow developing intermittents, and especially when 
there is a dropsical tendency. It is an important remedy in 
"brow-ague," and in the afternoon intermittents of nursing 
children. And it is often required where quinine has been used 
to excess. It vies with natrum muriaticum and f errum, in chronic 
malarial cachexia. 

The Arseniate of Quinia has been used with success in 
masked intermittents, and in mixed types of simple intermittent. 

Ipecac is frequently called for in mild intermittents of the 
tertian type. It resembles arsenic in many particulars. But 
its prostration is always greatest during the chill, while that of 
arsenic reaches its maximum after the heat. The gastric symp- 
toms are apt to predominate during both the paroxysm and in- 
termission. The intermission is seldom very complete. Ipecac 
will prove useful in cases that have been drugged with quinine 
or arsenic. It should always be thought of and compared 
with Pulsatilla when relapses are brought on by errors in diet. 
And in obscure cases it will frequently be a valuable remedy. 

Gelseirsiuiii follows ipecac well, and is oftenest indicated in the 
quotidian type of simple intermittent. It vies with arsenic in 
imported and slowly developing cases, and with eupatorium in 
such as have a tendency to run into remittents. The intermis- 
sion is apt to be short, and the paroxysms recur with marked 
regularity. Gelsemium is a valuable remedy in children's inter- 
mittents, and when relapses occur from sudden emotions. 

Natrum muriaticum is our best remedy in chronic and badly 
treated cases. It is also adapted to recent cases, and especially 



LEADING INDICATIONS. 61 

such as appear in newly-settled districts. The paroxysms recur 
daily. Natrum inur. is a common and efficient remedy for 
chronic malarial cachexia. 

Nux YOmica is one of the more important remedies for both 
the quotidian and tertian types. Its paroxysms are usually irreg- 
ular and show a decided tendency to anticipate. The gastric 
and bilious symptoms are generally prominent, and bronchial 
complications may co-exist. 

Pulsatilla is useful in cases of a changeable character, and. 
when the paroxysms take on a mild form and appear mostly in 
the evening. It is adapted to chlorotic states, and is indicated 
in pregnant women, when there is a tendency to abortion. Ee- 
1 apses from improper diet are frequently cured by this remedy. 

Ignatia is useful in mild cases occurring in nervous individ- 
uals. The intermission is usually complete. Ignatia frequently 
changes the type and almost always postpones. It is the rem- 
edy for tertians that change to quartans. 

Eupatorium perf. is indicated in those severe types of inter- 
mittent that approach the remittent, and are marked by a very 
imperfect intermission. "Aching of the bones" is its great 
characteristic. "Bonesettea" is a well-known popular cure in 
malarious districts, for "fever and ague." For the double ter- 
tian type of intermittent it is a most valuable remedy. 

Capsicum will occasionally be of service in simple intermit- 
tents occurring during the summer months. 

Cedron and Aranea are adapted to intermittents of new dis- 
tricts in warmer climates, when the paroxysms recur with clock- 
like regularity. And Polyporus officinalis and p. pinicola are 
recommended by our western physicians as remedies for the 
quotidian type of simple intermittent fever. 

Leading Indications. — The leading indications for these, our 
main remedies for simple intermittent fever, as well as for oth- 
ers that are occasionally of service, may for convenience of 
study be arranged according to the following compilation: 

Aconite. — In recent cases occurring in dark-complexioned,, 
plethoric young persons, and in relapses from exposure to 
changes of temperature; great thirst for small quantities of cold 



■62 LECTURES ON FEVERS. 

water prevails during the paroxysm (ars. and not. mur., opp. 
bry. ) ; the pulse is thready during the chill, but full, hard and fre- 
quent during the fever; the chill passes from the feet to the 
chest and head, and coldness is caused by the slightest move- 
ment (nux). The fever runs high and is apt to be prolonged; 
it is frequently attended with cough; there is great restlessness, 
anxiety and nervous excitability; the sweat is frequently profuse 
and brings relief {not. mur., opp. mere). 

Ammonium mur. — Is adapted to fat, lazy people. Chilliness 
recurs as often as the patient awakes. During the heat there 
is redness of the face, and stinging sensation in the skin ( apis, 
nit. acid)j flushes of heat with profuse sweat on the extrem- 
ities. 

Anacardium. — In nervous, hysterical females, and in nursing 
children; mild intermittents in hypochondriacs; patient is 
very irritable and passionate (bry., cham. ) ; shivering, as from cold 
water down the back; the fever returns every afternoon at 
four o'clock ( lycop. ) ; sweat principally on the chest and abdomen; 
dull pressure as from a plug in different parts is very character- 
istic. 

Alstonia. — After abuse of quinine; great debility and extreme 
prostration; rigors, cold sweats and diarrhea; useful in masked 
intermittents with dysentery. 

Antimonium crud. — Especially suitable for aged persons and 
young people who grow fat; predominance of gastric symptoms 
(ipec, puis., nux); thick, milky white coating on the tongue 
(bry., mere, nux) ; great sadness, and a w^oeful mood; aversion to 
food; strong desire for acids, particularly pickles (ars.); alter- 
nate constipation and diarrhea; absence of thirst (puis., quinine) ; 
great desire to sleep (apis); the chill appears about mid-day; 
chilliness predominates (menyantJies); vomiting during the 
heat (not. mur.); pulse irregular and rapid; sweat comes imme- 
diately after the chill with the heat, but soon disappears, dry 
heat continuing. 

Apis mel. — Is often useful in quotidian fevers, and in pro- 
tracted and badly treated cases; the sweat stage may be absent; 
there is great desire to sleep; awkwardness; soreness of limbs 
and joints; great sensitiveness to touch and pressure; soreness 
in the region of the spleen; general oedema; urine scanty and 



LEADING INDICATIONS. Go 

high-colored; white tongue, with diarrhea (ant. cruel.); chilli- 
ness from motion or uncovering (mix); chill about 3 p. M. ; 
worse in a warm room or near a stove; it begins in front 
of chest, abdomen and knees ; urticaria as the chili passes off; 
urticaria, with intolerable itching, at night (am., led.); thirst 
with the chill (ign., caps. ) ; no thirst with the heat (puis. ) ; desire 
for milk; during the paroxysm oppression of the chest with a 
sensation of smothering. Natrum mur. follows apis well, but 
rlius tox. does not. 

Aranea. — Long-lasting chill without thirst; heat and sweat 
often absent; paroxysms at the same hour every day or every 
other day (cedron); chilly feeling, worse on rainy, cold days 
(rlius); headache, better in the open air; nocturnal toothache; 
tongue slightly coated, with bitter taste; nausea and anorexia; 
weight in epigastrium as from a stone ( bry., ars., 2^>uls. ) ; enlarged 
spleen; menses too early and too profuse ; heaviness in the limbs, 
so that she can scarcely move them; numbness in the ring and 
small finger, and along the periphery of the ulnar nerve (conium). 

Arnica. — In sanguine temperaments and after abuse of qui- 
nine; relapsing cases; especially when there is a bruised, sore 
feeling; must lie down, yet the bed feels too hard (bapt.); in- 
different mood; forgets the word he is about to speak (baryta, 
rhus.); eructations bitter, and like rotten eggs (cham.); offensive 
flatus smelling like rotten eggs; drawing pains before the chill; 
chill in afternoon or evening, most severe in the pit of the stom- 
ach, with thirst for large quantities of cold water (bry., eupat. 
perf., opp. ars.); great heat in head, with coldness of the body; 
cold sensation at small spot on forehead; heat intolerable during 
the hot stage, but the slightest motion of the .bedclothes causes 
chilliness; urine scanty, brick-dust sediment ( lye. ); sour, offen- 
sive sweat, like mouldy earth. 

Arsenicum alb. — In the tertian type of intermittents, when the 
paroxysms are either incomplete, or else well-marked and vio- 
lent, and in fevers contracted at the sea-shore (gels.); the inter- 
mission is never clearly defined; the paroxysm's appear mostly 
in the afternoon, and may anticipate one hour every alternate 
day; they sometimes recur every fourteen days; after abuse of 
quinine; sad, tearful, anxious mood (ign., p> u ^s.); great rest- 
lessness; fear of death (aconite); great weakness and prostra- 



64 LECTURES ON FEVERS. 

tion; desire to lie down (arnica); headache, vertigo, and pale- 
ness of face and lips; sallow, clay-colored complexion; pain 
and distension in the left hypochondrmm ; intense burning 
pains in the stomach and pit of the stomach; aversion to food; 
tongue furred, at the edges, with red streak down the center, and 
red tip; pulse small, weak and compressible; sleepiness the 
night before the paroxysm (opp. quinine); yawning and stretch- 
ing before the chill; chill irregularly developed, and frequent 
ly mixed with the heat (mix); internal chill with external 
heat and red cheeks (cede); chill ameliorated by external 
warmth (opp. apis, am., ipec, puis.); scarcely any thirst dur- 
ing the chill; drinking increases the chill and causes vomiting; 
chilliness and shuddering without thirst, worse in the open air; 
external coldness, with cold, clammy sweat; the cold stage is 
frequently absent, the hot stage predominating; or, the chill 
and heat may predominate, with little or no sweat; the fever 
may be either wanting or mixed up with the chill, or else is in- 
tense and long -lasting; hiccough at the hour when the fever 
ought to have come; great restlessness during the heat; great 
thirst for cold water; wants little at a time, but often (quinine, 
opp. bry.); burning in the stomach and vomiting; great rest- 
lessness during the heat; cold, clammy sweat, with excessive 
thirst for large quantities of water; great weakness and pros- 
tration after the paroxysm. 

Belladonna.— In quotidian and congestive intermittents, in 
plethoric lymphatic constitutions; masked intermittents associ- 
ated with severe neuralgia; great irritability; whining mood; 
the hot stage predominates; chill commences in the scrobiculus 
cordis; shivering running down the back, and terminating in the 
pit of the stomach; chilliness in the arms; seldom any thirst; 
the face is pale when lying down, but red when sitting up ( opp. 
aconite); intense burning heat inside and out; averse to uncov- 
ering; sensitive to light and noise; throbbing carotids (glon.); 
bursting headache; very red face; eruption in the corners of 
the mouth or on the lips ; choking sensation in the throat, with 
dryness of the mouth ; tongue is red and dry along the edges, and 
white in the center; the papillae are bright and prominent (tart, 
emet.); sweat starting at the feet and passing upwards; sweat on 
covered parts only; sweat stains the linen yellow; the sweat stage 
may be entirely wanting. 



LEADING INDICATIONS. 65 

Bryonia. — In interniittents after getting wet {cole, carb., rhus) ; 
with thirst in all the stages; anticipating type; the patient is 
very irritable, and easily angered ( anac. ) ; apprehensive ; dreams 
about business and household affairs; constipation; stools dry 
and hard as if burnt; gastric symptoms predominate (ant. cruel. ) ; 
patient has to move frequently; the parts feel sore (arnica) ; 
feels best when lying on painful side (puis.); stretching and 
drawing in the limbs; desire to lie down during the paroxysm; 
sitting up causes nausea and vomiting; vomiting, first of bile, 
then of fluids (opp. not. mur.). 

The chill predominates, and is creeping rather than shaking 
in character. Violent throbbing headache, as if the head would 
burst, before the chill; chill begins in the lips, tips of fingers 
and toes; pain, as if dislocated, in the wrist and ankle (rhus. 
ruta); violent, dry, racking cough during the chill, continuing 
through the heat, with stitching pains ; patient holds the ster- 
num when coughing; stitches in the spleen (ceanothus) ; great 
thirst for large quantities of water, with cough, during the hot 
stage; heat on moving (o-p-p. bell, nux); burning internal heat, 
as if molten lead were running through the blood-vessels (ars., 
rhus): profuse, sour, oily sweat (china); sweat on single parts 
only, or on side on which patient lies ; sweat from the least exer- 
tion; all the symptoms are worse in a warm room and better in 
the open air. 

Cactus. — In quotidian interniittents when the intermission is 
complete and the paroxysm returns at 11 A. m. or 11 p. m. ; re- 
lapses from exposure to the sun's rays; prolonged chill not re- 
lieved by covering (aranea); coldness of the back, and icy 
coldness of the hands; long-lasting heat with dyspnoea and short- 
ness of breath (ars., p>hos.); flushes in the face; insupportable 
heat in the abdomen; lancinating pains in the heart (spig.); 
sense of constriction in parts; profuse sweat with unquenchable 
thirst. 

Calcarea carb. — In leucophlegmatic temperaments; large bel- 
lied individuals and persons who take cold easily; chronic inter- 
niittents; the intermission is never very clear; paroxysms at 2 
p. M.; thirst during the chill; chill begins at the pit of the stom- 
ach with spasms, or a fixed, cold, agonizing weight; heat without 
thirst; fever at 11 A. m., without thirst and without previous 
chill; heat worse from bathing (opp. fluoric acid); profuse 



66 LECTURES ON FEVERS. 

sweat in the morning and on the slightest exertion; sweat with- 
out thirst; shortness of breath on going up stairs (ars.); un- 
digested stools (china); alternate constipation and diarrhea. 

Camphor. — Specially useful in pernicious malarial fevers; con- 
gestive chills; long-lasting, shaking chills; coldness of the skin; 
icy coldness of the whole body (iabac); deathly paleness of the 
face (verat alb.); cold, trembling tongue; heat, with disten- 
sion of the veins; increased by motion (opp. caps.); cold, ex- 
hausting, viscous sweat; great anxiety, weakness, and exhaustion; 
extreme sensibility to cold air (nux). 

Canclialagua. — In spring intermittents that are ushered in 
with a severe chill; the skin of the hands and feet after the 
sweat resembles a washerwoman's skin; patient has a good ap- 
petite during the intermission. 

Capsicum. — Midsummer intermittents in stout, phlegmatic 
individuals ; the intermission is tolerably clear; there is thirst 
before and during the chill; shuddering after drinking; the chill 
commences between the shoulders, and is relieved by putting 
something hot to the back; general coldness of the body; intol- 
erance of noise; no thirst during the heat; acrid sweat; sweat 
without thirst; burning mucous diarrhea; appetite but little 
impaired; ears and tip of nose red and hot towards evening; all 
stages relieved by motion. 

Carlbo veg. — In pernicious malarial fevers; irregular parox- 
ysms. Great prostration during the intermission; bloating of 
stomach between the paroxysms. Toothache, headache, and 
pain in the limbs precede the paroxysm ; thirst only during the 
chill (ign.); icy coldness of the body and cold breath; coldness 
of the tongue; coldness of the knees, even in bed (apis); chill 
beginning in the left hand; (in right arm, mere); left sided chill 
(causticiim); heat without thirst; loquacity during the heat 
(podo.); oppressed respiration {apis); desire to be fanned; 
the fever is succeeded by severe headache; profuse sour sweat; 
sweat even when eating (carbo an.); easy to sweat and easy to 
chill; spleen swollen and painful; livid spots on face; foetid 
breath; after abuse of quinine. 

Cedron. — In quotidian and tertian intermittents in low marshy 
regions, the chill predominates and the paroxysms recur 



LEADING INDICATIONS. 67 

with clock-like regularity (aranea); chill preceded by great 
mental depression and headache; chill without thirst at 3 a. 
m. or 3 p. m. ; icy coldness of the hands and the tip of the nose; 
•cramps with tearing pains in upper extremities ; heat with thirst 
for warm drinks; entire body feels numb; sweat with thirst; dry 
neat followed by profuse perspiration; general malaise and de- 
bility during the intermission. 

Chamomilla. — In children and nervous adults; gastric com- 
plications; the patient is very irritable and restless (bry.); ex- 
cessive sensitiveness to pain (coffea); thirst during the heat and 
sweat, none during the chill; chill usually slight, only on ante- 
rior portion of the body; shivering of single parts, and heat of 
others; one cheek red and the other pale; sour sweat, during 
sleep, mostly on the head with smarting of the skin (caps.); yel- 
low coated tongue; tongue white at the sides and red in the mid- 
dle (opp. tart emet); nausea and vomiting of bile, and diarrhea; 
frequent emissions of large quantities of pale urine. 

Cinchona. — The chill is preceded by nausea, headache, hun- 
ger, anguish, palpitation of the heart and great thirst. Chilli- 
ness after every drink {caps., eupat perf. ) ; general shaking, vio- 
lent chill without thirst, increased by drinking; chills alternat- 
ing with heat, skin cold and blue (nux); thirst before the heat, 
none during the heat; general heat with swollen veins; cheeks, 
though of natural heat are red, and feel hot to the patient; ca- 
nine hunger, or else aversion to food; great thirst during the 
sweat; sweating during sleep or on being covered; great lassi- 
tude and exhausting sweats during the intermission; ringing in 
the ears, and a feeling as if the head were enlarged {cole, nux); 
saffron yellow color of the skin; the patient looks jaundiced; 
-anaemic and cachectic appearance; spleen and liver swollen, 
and painful on pressure; urine scanty with yellow or brick-dust 
sediment; all symptoms are aggravated by motion or the slightest 
effort. 

Cimex. — The chill begins with clenching of the hands and 
violent rage; pain, particularly in the knee joints, during the 
-chill, as if the tendons were too short; thirst; can drink before 
the paroxysm begins, but during the paroxysm drinking causes 
violent headache and a gagging cough with dyspnoea. 

after the chill: is obliged to urinate 



(58 LECTUEES ON FEVEKS. 

after drinking; heat with pressure and gagging in the oesopha- 
gus; ravenous hunger after the heat; musty sweat, which re- 
lieves, without thirst; thirst during the intermission. 

Cilia. — In quotidian intermittents of scrofulous children; the 
intermission is never very clear, and warm symptoms predomi- 
nate; frequent tickling of the nose (phos. acid); clean tongue;, 
chill ascending from the trunk to the head, with hunger but no 
thirst; heat with redness of the cheeks, without thirst, after 
sleep; sweat usually slight, at times cold, especially on the 
hands, forehead and nose. 

Cocculus. — In children and hysteric females (tarantula) ; with 
spasmodic symptoms; severe colic during the chill (magn. phos. ) ; 
aversion to sour things (opp. ant. crud.); obstinate constipation; 
all symptoms aggravated by eating or drinking. 

Cornus florida. — In obstinate intermittents; the paroxysm 
is preceded for days by sleepiness, sluggish flow of ideas, and 
headache; during the chill the skin is cold and clammy; nausea 
and acidity of the stomach; throbbing headache during the 
fever; during the intermission there is debility, loss of appetite 
and painful bilious or watery diarrhea. 

Elaterium. — When urticaria appears after suppressed inter- 
mittents; the itching is relieved by scratching (ign. opp. rhus). 

Eupatoriiuii perf. — In double tertians, and in intermittents 
that tend to run into remittents; paroxysms end with vomiting 
of bile; hectic cough from suppressed intermittents (cinch.); the 
intermission is apt to be imperfect, and may be attended by a 
loose cough; bone pains in every stage; worse on the morning 
of one day and the afternoon of the next; skin sallow; tongue 
coated white or yellow; morning diarrhea, (podo); great 
thirst, vomiting and aching pains in the extremities before the 
chill; soreness of the eyeballs; chill 7 to 9 a. m.; chill spreads 
from the back; thirst, vomiting and pains in the back and 
limbs as if bruised or beaten (am.); moaning during the chill; 
chill followed by heat without perspiration ; nausea and vomit- 
ing at the close of the chill, aggravated by drinking; thirst dur- 
ing the heat, with bitter vomiting, headache, and pain in the 
limbs; shivering during the heat; sweat may be scanty or 
absent; it is slight or wanting when the chill is severe; or vice 



LEADING INDICATIONS. 69 

versa; perspiration increases the headache, but relieves all the 
other pains, (not. mur.). 

Eupatorium purp. — In tertian intermittents ; during the in- 
termission, vertigo with sensation of falling to the left; desire 
for cold acid drinks, (calc. sulphide;) tongue coated and brown 
in the center; deep, dull pains in the kidneys {herb.); pains in 
the arms and legs before the chill; chill begins in the lumbar 
region ( lach. ) ; severe pains in the bones with numbness of the 
legs; frontal headache ; blueness of the lips and nails (mix,) vio- 
lent shaking with little coldness; thirst during the hot stage; 
long lasting heat followed by hunger; sweat mostly on the 
upper part of the body, and usually slight. 

Ferrum. — In protracted intermittents after the abuse of qui- 
nine, when there are anaemia, debility and great muscular weak- 
ness; extreme paleness of the face, and of the mucous membrane 
of the lips and mouth; ague-cake, (ceanothus, berberis vulg.); 
vomiting as the chill appears; thirst with the chill; hands and 
feet cold and numb; no thirst during the hot stage; rush of blood 
to the head with flushes of heat in the face, hot flushes, (kali 
carb.;) red cheeks; sensations of heat all over the body, which is 
cold to the touch (opp. baryta carb.); heat in palms of the hands 
and soles of the feet; profuse, long-lasting, debilitating sweat; 
sweat, clammy, strong smelling, and stains the linen yellow; 
all the symptoms are aggravated by sweating (opx). nai. mur.). 

Gelsemium. — In recent uncomplicated quotidian intermit- 
ents, occurring in children and nervous young people; the par- 
oxysm usually begins, in the evening, though the fever may re- 
cur alone at 10 A. m. ; the intermission may be short or wanting, 
and there is great muscular prostration ; the chill begins in the 
hands and feet, and is unattended by thirst; the fever may be 
intense and burning, and accompanied by a sensation of fall- 
ing, especially in children; there is great mental anxiety, red- 
ness of the face and nervous restlessness during the hot stage ; 
the sweat is apt to be profuse, and relieves the pain (nai. mur., 
opp. ferrum. ) ; sweat most profuse on the genitals. 

Calcium Sulphide. — After abuse of mercury or potassium 
iodide; the patient is very sensitive to the cool air; fainting 
from the slightest pains; urticaria before and during the chill; 
violent shaking chill every morning without heat; burning heat 



70 LECTURES ON FEVERS. 

with headache and unquenchable thirst for acid drinks ; sleep- 
iness; intolerance of light; herpes around the mouth (not. mur.); 
continuous, profuse sweat without relief, increased by motion; 
offensive, sour-smelling sweat at night; sweat on perineum, 
groins and inside of thighs. 

Ignatia. — The intermission is complete; yawning, stretching, 
and shuddering before the chill; chill commences in the arms; 
twitching in the deltoid, (in biceps or triceps, fluor. acid); shak- 
ing chill with redness of the face; chilliness relieved by exter- 
nal heat, ( ars. ) ; thirst for large quantities of water, only during 
the chill, (caps. ) ; external heat and redness without internal heat; 
one side of the face red and burning, (am., cliam. ) ; urticaria over 
the whole body during the heat with violent itching, relieved by 
gentle scratching, (elaterium) ; desire to be uncovered during the 
heat; fainting as the hot passes into the sweating stage; sweat 
usually slight, most on the face. 

Iodine. — Quartan fevers in scrofulous individuals; emaciation; 
ravenous hunger, cannot be satisfied; constant diarrhea during 
the intermission; tenderness and hardness in the left hypochon- 
drium; ague-cake. 

Ipecacuanha, — In quotidian and tertian intermittents, and in 
cases that have been maltreated with quinine and arsenic; re- 
lapses caused by errors in diet, (puis. ) ; the paroxysm is preceded 
by yawning, stretching and salivation, and the intermission is 
never very clear; nausea is present in all the stages; the prostra- 
tion is greatest during the chill; the chill is aggravated by exter- 
nal warmth, (apis, opp. ars., ign. ); chill is lessened by drinking, 
(opp. eupat perf., cimex); nausea and vomiting, and dry, hack- 
ing cough during the heat'; alternate coldness and paleness of the 
face; sour sweat, stains yellow; turbid urine; symptoms worse 
during the sweat. 

Lachesis. — In tertian intermittents in drunkards and in 
women during the climacteric period; annual spring attacks 
(carbo. veg.); after abuse of quinine; all symptoms are worse 
after sleep; throat is very sensitive to the touch; filiform pulse; 
the chill predominates, and begins in the small of the back, ( eup. 
pnrp.,); chill is relieved by the heat of a stove, and by being 
firmly held ; shivering when moving the bedclothes, (mix vom. ) ; 
chill and heat alternating, and changing from place to place;, 



LEADING INDICATIONS. 71 

great talkativeness during the heat, {mar um ver.) which is gen- 
erally irregular; heat with desire to uncover; cyanosis during 
the fever: perspiration in axilla smelling like garlic; profuse 
sweat which affords relief. 

Lycopodmm. — In quotidian and tertian intermittents ; irreg- 
ular types; great fear of being left alone (opp. cinch.)', yellow- 
ish-gray color of the face (ars.); abdominal flatulence; sour 
eructations and sour vomiting; vesicles on the tongue; obstinate 
constipation; increased micturition; paroxysm at 6 to 7 p. m. ; 
yawning and nausea before the chill; chill starting from the 
back; shaking chill, great coldness even in bed, as if lying on 
ice; left sided chill (carbo. veg., opp. bry.); numb, icy cold hands 
and feet; cutis anserina; chilliness in the morning, followed by 
great heat; sour vomiting between the chill and the heat; sour 
vomiting during the hot stage; sore, pressive pain in the region 
of the liver; burning as from glowing coals between the scapu- 
lae; profuse sour sweat on the body; perspiration immediately 
after the chill (canst.); thirst after the sweat. 

Menyantlies. — In irregular intermittents when the cold stage 
predominates; quartan fevers; ravenous hunger; great desire 
for meat (opp. snlph., arnica); coldness of the distal parts; 
coldness in the abdomen, aggravated by pressure; the hands and 
feet are icy cold, the rest of the body warm; great heat without 
thirst; flushes of heat with hot ears and cheeks; sweat contin- 
uing all night. 

Natrum mur. — In quotidian intermittents in new districts ; 
after abuse of quinine; the intermission is never very clear; 
sallow complexion ; stitches in the hepatic region between the 
paroxysms; loss of appetite; bitter taste {bry., puis.); dry, white- 
coated tongue; feeling as of a hair on the tongue (Jcali bich.); 
herpes on the lips, (ars.); ulceration of the corners of the mouth; 
frequent vomiting of water and mucus before the chill; chill 
from 10 to 11 A. M. ; long-lasting, violent chill with blueness of 
the lips and nails (mix); thirst for large quantities of water 
and often (bry.); prolonged heat with thirst; hammering frontal 
headache; excessive weakness during the heat; red sandy sedi- 
ment in the urine ( lye. ) ; cutting in the urethra after micturi- 
tion; profuse sweat which relieves all the pains except the head- 
ache (eupat perf.). 



72 LECTUEES ON FEVEES. 

Nux Tomica. — Anticipating intermittents in thin, slender 
individuals; irregular paroxysms, at night or early morning; 
gastric and bilious symptoms predominate ; tongue coated, white 
or yellow; must rinse the mouth, it tastes so bitter; constipation; 
soreness of the spine; extremities feel as if paralyzed at the 
onset of the chill; heat or sweat, occasionally before the chill; 
shaking chill with blueness of the face and hands ; pain in the 
sacrum during the chill; severe, long-lasting chill, not relieved 
by warmth; congestive chills; great thirst, especially for beer, 
during the heat; long-lasting, burning heat, yet can neither un- 
cover nor stir without feeling chilly; headache, vertigo, pain in 
chest and vomiting during hot stage; sweat without thirst; pro- 
fuse sweat after the severest paroxysms ; chilliness on moving 
the bedclothes; extreme sensitiveness to the cold air {cample, 
coca). 

Opium. — Is especially adapted to children and old persons; 
great drowsiness in all the stages; stertorous breathing; face 
bloated, dark red and hot; twitching of the extremities; con- 
gestive chill. 

Podophyllum. — In bilious temperaments; loss of appetite; 
breath offensive and disgusting to the patient; tongue coated 
white, shows the imprints of the teeth (mere); morning diar- 
rhea, changeable in character; pressing pains in the region of 
the liver and spleen; severe backache before, but not during, the 
chill; chill at 7 A. m. ; great loquacity during the chill; dull ach- 
ing in the joints of the extremities; no thirst during the chill; 
heat with excessive thirst, commencing even during the chill; 
violent pains in the head; profuse sweat; sleeps^ during the 
sweat (apis). 

Polyporus. — In stubborn quotidian intermittents; the inter- 
mission is short and the paroxysm begins mostly in the morning; 
there is considerable derangement of the abdominal viscera, 
with dull headache and jaundiced skin; numb sensations after 
the paroxysm; chill begins in the inter-scapular region (caps.); 
headache; slight thirst; mild but long-lasting fever; inertia 
and lassitude; very little thirst during the fever; the face is hot 
and flushed; slight but long-lasting sweat without thirst; rarely 
cf service in autumnal intermittents. 



LEADING INDICATIONS. 73 

Pulsatilla. — Adapted to women and children, and to individ- 
uals of mild, sensitive temperament; irregular types; quartan 
intermittents; relapses from dietetic errors; recurring every 
fourteen days; all stages of paroxysm are mild and frequently 
mixed up; constant chilliness and headache during the intermis- 
sion; changing symptoms; tongue thickly coated, white or yel- 
low, and covered with a tenacious mucus ; bad taste in the mouth 
in the morning; disgust for fat food (opp. mix); mucous diar- 
rhea; profuse watery urine; diarrhea and drowsiness the day 
before the paroxysm; chill at 4 P. M., without thirst; one-sided 
coldness; chilliness over the abdomen extending around to the 
back ; acidity of the stomach, and vomiting of mucus and bile ; 
chill and heat simultaneous (ars.); dry heat of the body with 
distended veins, and burning hands; thirst only during the heat; 
external warmth is intolerable (sepia); desires to be uncovered 
(ajjis); feels for cool places in the bed; one-sided sweat, mostly 
on the left side ; talkativeness when sleeping during the sweat; 
chlorotic states; menstrual irregularities. 

Quinine. — (Chinium sulph.) In tertian intermittents when 
the paroxysms recur at the same hour; and in quotidian inter- 
mittents that anticipate two hours every day; the intermissions 
are clearly denned; there is great debility, prostration and thirst 
between the paroxysms; the urine is fatty and deposits a straw 
yellow or brick-dust sediment; pain in the region of the liver 
and spleen; ringing in the ears; dizziness and enlarged feeling 
in the head; pain in the dorsal vertebrae on pressure, during the 
paroxysm ; decided shaking chill with thirst at 3 p.m.; shaking 
chill with severe pains in the left hypochondrium; chili with 
blueness of the lips and nails (mix); heat, with great thirst; 
general heat, with redness of the face; enlargement of the veins 
of the legs and arms ; delirium during the hot stage ; heat grad- 
ually passes into sweat; violent heat, with frequent yawning 
and sneezing, followed by copious sweat; sweat, with thirst; 
profuse sweat during perfect quiet; sweat relieves all other 
symptoms, but aggravates the headache; drinking is generally 
grateful and affords relief. 

Rhus tox. — In quotidian intermittents which tend to run into 
remittents; relapses from getting wet; evening paroxysms; burn- 
ing in the eyes ; yawning and stretching, and a feeling in the maxil- 



74 LECTURES ON FEVERS. 

lary joint as if sprained, before the paroxysm; dry, teasing cough 
before and during the chill (rumex); none during the heat; 
(during the heat, aconite); tongue coated white with red, dry, 
triangular tip ; stretching and pain in the limbs; chill aggravated 
by drinking; constant chill, as if cold water was poured over 
him (led. ) ; feeling as if the blood was running cold through the. 
vessels (opp. ars. ); alternately red and pale face; fever may 
either precede or succeed the chill; excessive heat as from hot 
water running through the vessels ; great restlessness, constantly 
changing position (ars., opp. bry.); thirst for cold water or cold 
milk; drinks little at a time but often; profuse sour morning 
sweats; sweat even during the heat; sleep during the sweat; 
urticaria which passes off with the sweat. 

Sabadilla. — The chill predominates; chill always passes from 
below upwards (opp. verat); dry, spasmodic cough during the 
chill, with tearing in the limbs; paroxysms recur at the same 
hour (aran., cedron) ; constant chilliness during the intermission; 
alternate attacks of hunger and loathing of food. 

Sambucus. — When the perspiration continues through the 
intermission ; profuse sweat when awake, dry heat during sleep ;. 
deep, dry, racking cough, for half an hour before the chill. 

Sepia. — In chronic cases; intermittents in pregnant and nurs- 
ing women; monthly paroxysms; perfect absence of thirst (puis. ) ; 
coldness begins in the feet and passes upwards ; chilliness from 
motion (mix); sensation as if the limbs and ringers were dead; 
icy cold and damp feet all day, like standing in cold water; ex- 
ternal warmth unbearable (puis.); flushes of heat (sulph.); ver- 
tigo ; sensation as if hot water was being poured over him, dur- 
ing the heat; profuse sweat in the morning after awaking. 

Sulphur. — In chronic cases and in chronic malarial cachexia; 
great prostration after every paroxysm ( ars. ) ; with thirst for 
beer; diarrhea in the early morning; chill begins in toes or sa- 
crum ; icy coldness of the genitals ; dry skin with heat and burn- 
ing in the soles of the feet during the fever; sweat from the least 
exertion (mere); profuse sweat at night, with restlessness; sul- 
phur is often serviceable to arouse the reactive power of the 
system. 

Yeratrum alb. — In pernicious malarial fevers; children's. 



PALLIATIVE AND DIETETIC TREATMENT. 75 

intermittents, when the paroxysm begins at 6 a.m.; severe long- 
lasting chill; chill with coldness and thirst; profuse cold sweat, 
with deathly paleness of the face; desire for cold drinks; great 
exhaustion during the intermission. 

TREATMENT FOR THE SEQUELS. 

Merc. hin-iod. — For enlarged spleen. It may be given inter- 
nally from the 2nd to the 6th trit, and also used as an ointment, 
of five per cent, strength, externally. 

Phosphorus for deranged liver. 

Chelidoniiim for obstinate neuralgia of the fifth nerve, after 
masked intermittents. 

Arsenicum and Natrum Mur. for chronic malarial cachexia. 

Ferritin or Arseniate of Iron for anaemia and debility before 
the occurrence of oedema; and Pulsatilla when chlorosis and 
hydraemia have been induced. 

PALLIATIVE AND DIETETIC TREATMENT. 

During the intermission a nutritious diet should be indulged 
in. Meat essence or beef tea, tender meat, milk, and fre- 
quently wine may be taken. 

When gastric irritability continues during the intermission, 
benefit will accrue from the use of milk or beef tea and pepsin 
enemas. At the onset of the paroxysm the patient should take 
to the bed, and abstain from all manner of food until it is over. 
During the stage of chill relief is frequently experienced 
from galvanism applied to the spine. Too much covering is 
generally burdensome, and should not be allowed. Should this 
stage be protracted, or the vital powers become weakened, stim- 
ulants and external warm applications must be resorted to. As 
the hot stage approaches the bed-covering may be gradually re- 
moved, and the body frequently sponged with tepid water if the 
heat is very great. During the sweat stage allow the patient to 
rest; wipe away the sweat with warm cloths, and change the linen 
when the sweat is excessive. 

Use stimulants whenever there is a tendency to collapse in 
debilitated subjects. But unless specially needed all alcoholic 
beverages should be strictly avoided. 



LECTURE V. 

Simple Remittent Fever. 

I sliall invite your attention this morning to the second in oar 
list of malarial fevers, namely: Simple Remittent Fever. 

Definition. — A continued fever with daily exacerbations, due 
to the presence of the bacillus malarise in the blood. It is 
ushered in by a chill, and is characterized by frontal headache, 
epigastric uneasiness, functional disturbance of the liver and 
occasionally jaundice. Toward the end of the first week the 
daily remissions may become less and less distinct, and typhoid 
symptoms supervene. The average duration of simple remit- 
tent fever is two weeks. Mild cases may terminate within six 
days. Uncomplicated cases rarely prove fatal. After death, 
evidences of catarrhal inflammation of the intestinal tract, with 
bronzed liver, and pigmentation of the blood and tissues are 
found. 

Synonyms. — Bilious fever, bilious remittent fever, continued 
fever, acclimative fever. 

Historical Notice. — Simple remittent fever is pre-eminently a 
disease of warm climates and malarial districts. In this coun- 
try it is most prevalent in the southern and western states, and 
may be endemic during the summer and autumn months. It 
is the fever of Hungary, Africa, and the Pontine marshes of 
Italy. Alexander the Great, James I. and Oliver Cromwell are 
said to have died of it. 

Etiology. — This has been considered already in our lecture 

76 



CLINICAL HISTOBY. 77 

on simple intermittent fever. Xo doubt can at the present day be 
reasonably entertained but that an intenser action of the same 
malarial poison — the bacillus malarise — which gives rise to inter- 
mittent fever, can produce remittent fever. Malarial epidemics 
frequently begin as intermittents, change to remittents at their 
height, and return to intermittents during their decline. As a 
rule, the two forms of fever do not prevail in the same locality 
at the same time. Sporadic cases due to peculiarities of con- 
stitution and differences in susceptibility to the poison may 
however occasionally occur within the same area. In the same 
latitude, malarial fever may be remittent along the sea coast, and 
at the same time intermittent on the high lands. Simple remit- 
tent fever has the same geographical limits, and is governed by 
the same laws of development and distribution, as simple in- 
termittent fever. Its boundaries, from 63° north latitude to 57° 
south latitude, encircle the earth as with a broad, irregular belt, 
running in the main parallel with the equator. At the northern 
and southern limits of this malarial zone the types of fevers are 
rare as to frequency and mild in character, but become extremely 
prevalent and severe on approaching the equator. Other things 
being equal, remittents require a higher average range of tem- 
perature than is necessary for the development of intermittents. 

Clinical History. — The premonitory stage of this disease is 
usually short, but its attending phenomena are well marked. 
The initial symptoms are those of general malaise, with head- 
ache, sleeplessness and oppression in the epigastrium. After 
twenty-four or forty-eight hours the attack commences, not 
gradually but abruptly, and mostly with a chill. As a rule, the 
chill is not so severe nor of as long duration as that of intermit- 
tent fever. It appears as a general coldness of the surface, 
rather than as a shaking of the body with chattering of the 
teeth. During the chill, as in the cold stage of intermittents, 
the thermometer in the axilla will show a rise of two or three 
degrees in the temperature of the body. Accompanying the 
chill there is intense headache, with pain in the back and limbs. 
Following the chill, which is from half an hour to an hour in 
duration, the febrile condition appears, and continues unabated 
for six, twelve, or even forty-eight hours. The temperature may 
at this period of the attack reach 105° or 106° Fahr. The skin 
becomes hot, dry and harsh. The pulse increases in force and 



78 LECTUKES ON FEVEKS. 

frequency, but seldom exceeds 110 or 115 beats to the minute. 
The face becomes flushed and the eyes suffused. The patient is 
restless, sleepless, and incapable of mental exertion. The op- 
pression and tenderness at the epigastrium increase, and nausea 
and vomiting become more persistent. The vomiting is at first 
of the contents of the stomach, and afterward of a stringy mu- 
xsus, tinged with green. In severe cases, black vomit may occur. 
The tongue becomes coated, and there is great thirst. The uri- 
nary secretion becomes scanty, and is loaded with urea. The 
bowels are usually constipated at the beginning of the attack. 
When diarrhea occurs, the stools are tinged with bile. After 
continuing with increasing severity from ten to twelve hours, 
these symptoms begin to subside ; a slight perspiration appears 
upon the forehead, and extends in a short time over the entire 
body; the pulse falls ten or twenty beats per minute, but never 
reaches the normal. The thirst diminishes and the irritability 
of the stomach lessens. The headache almost disappears and 
the patient falls into a quiet and refreshing slumber. The tem- 
perature declines as the symptoms abate, but never entirely 
Teaches the natural standard. Usually in from four to twenty- 
four hours the febrile movement re-appears with increased se- 
verity, preceded or not by a slight chill. The patient's discom- 
fort again increases, and the restlessness becomes extreme. The 
headache returns, and delirium may at times appear. The gas- 
tric symptoms are now marked and severe. The tongue is thickly 
covered with a yellowish coating. The skin becomes hot, dry 
and jaundiced. 

All the symptoms of this, the second exacerbation, resemble 
those of the first, but are more severe and of longer duration. 
The partial subsidence of the fever is attended by a less profuse 
perspiration than during the primary paroxysm, and the remis- 
sion is not so well marked. 

The period of increase of fever is known as the exacerbation. 
The time that elapses between the subsidence of the fever and 
the appearance of the exacerbation is called the remission. 

Exacerbations and remissions are characteristic of a fully de- 
veloped case of simple remittent fever. The exacerbations are 
apt to occur about midday, and the remissions at midnight. In 
protracted cases the remissions may not occur until morning. 
Oftentimes the paroxysm follows the double tertian type, and 



CLINICAL HISTORY. 79 

then tlie exacerbation occurs one day in the morning and the next 
da} 7 in the afternoon. In severe attacks, the paroxysm may be 
that of a double quotidian. One paroxysm will then appear at 
noon and another at midnight; the remissions taking place in 
the evening and morning. 

After the second paroxysm the advance is various. Usually 
on the third day the exacerbation again appears, severer in form 
and of longer duration than the preceding one. The remission 
succeeding is proportionately more incomplete. From day to 
day the febrile symptoms continue to recur and abate, until 
the remissions disappear and the fever assumes the continued 
type, or else become more marked, and eventually pass into in- 
termissions. In favorable cases the disease shows signs of de- 
cline after the fifth exacerbation. If, however, the disease pro- 
gresses, by the end of the first week the remissions are no lon- 
ger discernible, and the fever becomes a continued fever. 

Each returning exacerbation from this time on tends only to 
lower the patient into that typhoid state which is frequently 
mistaken for typhoid fever, but which is liable to occur in all 
fevers. The skin now feels extremely dry and harsh ; the coun- 
tenance is dark or flushed; the tongue becomes parched; dark 
and black matter, called sordes, collects upon the teeth; a brown- 
ish diarrhea at times takes the place of the constipation. In 
some cases there is local tympanites. Muscular debility is usu- 
ally great. The pulse numbers 120 or 140 beats per minute, and 
is small, thready and feeble. All the symptoms deepen, and 
ataxic phenomena appear. Deglutition becomes difficult. The 
patient is unable to raise himself, and is continually sliding 
down in bed; his hands tremble, and there is subsultus tendi- 
num and carphologia. 

This order of things may continue for a week or ten days ; 
when, if the patient is to enter upon convalescence, remissions, 
frequently attended by a critical discharge from the kidneys, 
bowels or skin, become more and more marked, and the febrile 
exacerbations gradually disappear. In fatal cases the remissions 
do not take place, but the typhoid symptoms deepen, and death 
ensues either from exhaustion or as a consequence of complica- 
tions. Death from exhaustion occurs more among the aged, 
and in intensely malarial regions. Otherwise, death within the 
first three weeks is almost always the result of inflammatory 



80 LECTURES ON FEVERS. 

complications. Meningitis, gastritis and pneumonia are among 
the most frequent complications; while chronic hepatitis and 
splenitis appear later, and may be considered as sequels rather 
than as complications. The sequels are oftentimes more to be 
dreaded than the disease. 

When simple remittent fever is accompanied by a more than 
usually severe gastro-hepatic catarrh, as evidenced by excessive 
bilious vomiting and jaundice, it has been termed by some writ- 
ers, bilious remittent fever. 

ANALYSIS OF CHART. 

Chill. — The onset of the fever is generally abrupt, usually 
with a chill. The chill is less complete and of shorter duration 
than that of either intermittent fever or pneumonia. A general 
coldness of the surface is present at the beginning of the chilly 
sensation. The shaking of the body and chattering of the teeth, 
common in intermittents, are not experienced in remittents. 
There is rarely a marked chill after the first paroxysm. 

Paroxysms. — The paroxysms during the first week are made 
up of exacerbations and remissions. When the fever is prolonged 
into the second week the remissions disappear, and reappear 
only as convalescence begins to be established. The tempera- 
ture of simple remittent fever varies from 100° to 105° Fahr. 
During the first two days it is from 1° to 2° lower during the 
remission than during the exacerbation. At the time of the in- 
itial chill it is from 2° to 3° above the normal. After the third 
day, unless convalescence sets in, there is but little fluctuation. 

The Circulatory and Respiratory Systems. — The pulse 
increases in frequency as the temperature rises, and may reach 
110 or 120 beats per minute, in the primary paroxysm. During 
the first remission it may fall ten or twenty beats per minute. 
After the third paroxysm it becomes more frequent, and is 
apt to be small, thready and feeble. The respirations are 
moderately accelerated during the exacerbations of the first 
week, and may range from 20 to 25 per minute in uncomplicated 
cases. During the period after the first week the respirations 
may be either hurried and shallow, or else abnormally slow. 

The Nervous System. — Headache is one of the earlier and 
more constant symptoms. It is usually present among the pro- 
dromes. It is most severe during the first week, and terminates 



CHAKT. 

CHAKT III.— Simple Remittent Fever. 



81 



Premonitory 
Symptoms : 



Initial Symptoms 



Malaise. 



Xausea, 



Cephalalgia, 



Coated Tongue. 



Abrupt chill. A general coldness, lasting from V 2 to 1 hour. 



General 
Symptoms : 



Durimr first week. 



Form, 



Quotidian, Double Tertian or Double 
Quotidian. 



Stage, 



Exacerbation, 



Remission. 



After first week. 



Continued fever. 

Exacerbations 

without remissions. 



Temperature : 



103° to 106°, 



103° to 106°. 



Pulse : 



Full. 
110 to 120 
per minute. 



Respiration : 



Hurried, 



Nervous system: 



Throbbing headache, 
Restlessness, 
Sleeplessness, 



Stomach 



Thirst, nausea. 
Epigastric uneasi- 
ness. Vomiting of 
green, stringy mucu? 



B ! 

x a 



c c K 



Small and feeble, 
120 to 110 
per minute. 



Quick. 



Active delirium, 
Subsultus tendinum 
Carphologia. 



Vomiting 
less constant. 



Face : 



Flushed, 



Flushed. 



Eyes : 



Suffused, 



Dull and 
expressionle? 



Muscular svstem: 



Violent pain in back 
and limbs. 



Great muscular 
debilitv. 



Urine : 



Scanty, 



Loaded with urea. 



Skin 



Dry — yellow, 



Slight perspiration, 



Dry, hot and 

jaundiced. 



Tongue: 



Yellow coating. 



Dry and fissured. 
Sordes on teeth. 



Bowels : 



Constipated. Diarrhoea at close of week. 



Brownish diarrhoea. 



Complications: 


Meningitis, Cerebritis, Gastritis, Enteritis and Pneumonia. 


Sequels: 


Chronic hepatitis and splenitis. 


Duration : 


If clays. May terminate before the fifth day. 



Prognosis: 



Favorable. 



Etiology : 



The Bacillus Malaria?. 



82 LECTURES ON FEVERS. 

after that time upon the advent of delirium. Wakefulness is 
often a prominent and annoying symptom. Subsultus tendinum, 
carphology or grasping in the air, and picking at the bedclothes, 
may appear during the typhoid state in cases prolonged beyond 
the first week. 

The Digestive Tract. — The affections of the digestive sys- 
tem consist mainly of perverted functions, and of catarrhal con- 
ditions of the mucous membrane of the alimentary tract. The 
tongue is at first coated with a whitish or yellowish-white fur. 
The edges present, as in malarial diseases generally, a pectini- 
form appearance; the margins are smooth, and both present a 
clearer appearance and a brighter hue than the remainder of the 
surface of the organ. After the first week, in severe cases, the 
tongue becomes parched, and at times cracked. Sordes begin to 
collect upon the gums and teeth, if the fever runs high and is 
prolonged beyond the first week. 

Thirst is a prominent symptom, especially during the exacer- 
bation. Nausea and vomiting are invariably present. The mat- 
ters ejected usually consist of thin, stringy mucus, tinged with 
green. In severe attacks there may be a slight amount of black 
vomit. Epigastric tenderness is generally well marked. The 
liver is slightly enlarged in most cases. Constipation is a com- 
mon symptom. When diarrhea occurs, it is usually mild, and 
the evacuations are brownish in character. In rare cases it may 
be so excessive as to endanger the life of the patient from pros- 
tration. The skin is generally dry and more or less jaundiced. 

Morbid Anatomy.— The pathological changes of simple re- 
mittent fever resemble very much those of simple intermittent 
fever. And as both types of fever are due to the action of the 
same malarial poison, with only a difference in quantity, the 
same characteristic changes in the blood are experienced in both 
with a difference only in degree. The number of red blood 
globules is diminished in both, as is also the amount of fibrin 
and albumen. And there is an accumulation of a variable 
amount of yellowish-red, brown or black pigment matter. This 
pigment matter (Fig. 9) is present in the form of granules or of 
cells containing granules, in the blood, spleen, liver, kidneys, 
brain, spinal cord, etc. These granules are oftener present in 
remittent than in intermittent fever. Their accumulation in the 



DIFFERENTIAL DIAGNOSIS. 83 

general circulation can easily be shown in a drop of blood drawn 
during life, after a series of paroxysms have occurred. By some 
writers the spleen is thought to be the point of origin of this 
pigment matter; and by others the pigmentation is believed to 
be due to the hsematine, which has escaped from the corpuscle in 
consequence of changes in the plasma as regards the amount of 
albumen and sodium chloride it contains. The latest and most 
probable theory is that the granules owe their origin to the 
changes in the red corpuscle, caused by the destructive action of 
the bacillus malarise. 

The spleen is somewhat enlarged in simple remittent fever, 
but not to the same extent as in simple intermittent fever. The 
tumor seldom extends below the margin of the ribs. The 
changes in the alimentary tract are such as attend gastrointes- 
tinal catarrh. The mucous membrane of the stomach and in- 
testines is more or less congested, thickened and softened. In 
the intestinal canal, the Peyerian patches are usually enlarged, 
and at times ulcerative changes may have taken place. The 
mesenteric glands are frequently hypersemic, but are neither 
enlarged nor granular. 

The Liver. — The characteristic pathological lesion of remit- 
tent fever is the bronzed liver. 

This discoloration is uniformly present, though it may vary 
in degree in different types. It is bronzed without and olive- 
green within, and is due to the pigmentation of the liver tissues. 
The organ is seldom much increased in size. 

Differential Diagnosis.— Simple remittent fever is readily 
distinguished from simple intermittent fever. Each paroxysm 
of simple intermittent fever begins with a chill; while in simple 
remittent fever, after the primary paroxysm, there is rarely a 
marked chill. In intermittent fever there is a time when the 
patient is free from fever — the intermission; while in remittent 
fever, there is no time, not even during the remission, when the 
patient is entirely free from fever. 

The symptoms in remittent fever simply grow and decline, 
they do not as in intermittent fever, appear and disappear. 

Remittents often pass into intermittents, and vice versa. 
Simple remittent fever ought not to be confounded with typhoid 



84 LECTUEES ON FEYEES. 

fever. And yet, after the patient has passed the first week and 
entered the typhoid state, the mistake may easily be made. 

The sudden appearance of remittent fever stands in marked 
contrast to the insidious approach of typhoid fever. The range 
of temperature during the first week is very different. During 
the first week the remissions are very distinct in remittent fever, 
and there is frequently marked jaundice. The gastric symp- 
toms (nausea and vomiting) are common and severe in remit- 
tent, but quite rare in typhoid fever. Pigment granules are 
generally present in the blood of remittent fever patients, but 
are never found in typhoid fever. Epistaxis, bronchitis, and 
the rose- colored spots so common in typhoid fever, are seldom 
seen in the typhoid state of remittent fever. 

The "pea-soup" discharges of typhoid fever are entirely 
different from the brownish evacuations of remittent fever. 
The livid countenance, sleeping stupor, deafness, and tympa- 
nites are almost peculiar to typhoid fever. 

The post-mortem changes are gastric and hepatic after remit- 
tent fever, and enteric and splenic after typhoid fever. Remit- 
tent fever is developed only in malarial districts; while typhoid 
fever frequently prevails where remittents are unknown. 

Remittent fever differs from typho-malarial fever in the early 
appearance of enteric symptoms, and the well-marked typhoid 
phenomena of the latter. Typho-malarial fever has usually a 
longer prodromal stage than simple remittent fever. 

The differential diagnosis between simple remittent fever and 
yellow fever is sometimes attended with considerable difficulty. 
Pigment granules are found in the blood of remittent fever pa- 
tients, but not in that of yellow fever victims. 

Hemorrhage from the stomach, and albuminous urine, though 
seldom found in remittent fever, are frequent symptoms in yel- 
low fever. The headache of yellow fever is occipital, while that 
of remittent fever is frontal. One attack of yellow fever pro- 
tects from a second, while one attack of remittent fever rather 
predisposes to another attack. 

In yellow fever death may take place on the third day. The 
severest cases of remittent fever never end fatally before the 
seventh day. Simple remittent fever is always a country fever, 
while yellow fever is a disease of cities and sea-port towns. 

Prognosis. — The prognosis in simple remittent fever is gen- 



TREATMENT OF EEMITTENT FEYEE. 85 

■erally good. In our latitude fatal cases should rarely occur. 
As a rule, the prognosis is less favorable in tropical than in tem- 
perate climates. In the southern states where the severe forms 
are encountered, a fatal termination is of frequent occurrence. 

The favorable indications are: The early subsidence of the 
gastric symptoms; a lowering of the temperature range and a 
decrease in the frequency of the pulse; a turbid appearance of 
the urine and the formation of vesicles about the lips. Decided 
and prolonged remissions accompanied by copious perspiration 
are always signs of approaching convalescence. 

On the other hand, short and incomplete remissions with a 
tendency to collapse at the close of the exacerbations are un- 
favorable signs. Other suspicious symptoms are increased fre- 
quency and extreme weakness of the pulse; dryness and black- 
ness of the tongue; hiccough; intense icterus, and retention or 
suppression of urine. The advent of cerebral symptoms or of 
pneumonic or gastric complications are additional alarming 
danger signals. 

An attack of simple remittent fever predisposes to subsequent 
attacks of simple intermittent fever, while such sequels of the 
latter disease as enlargement of the spleen, anaemia and general 
dropsy, occasionally follow. 

Duration. — The average duration of simple remittent fever 
is fourteen days. Favorable cases often terminate in an inter- 
mission on the fifth day. Severe or ill-managed cases may be 
protracted for three, five or even six weeks. 

Treatment. — The prophylactic treatment is the same as for 
intermittent fever. 

Gelsemium, bryonia, eupaiorium and quinine are the principal 
remedies during the attack. 

Gelsemium is especially useful during the first week, and 
will often terminate the fever before the fifth day; it is adapted 
to cases coming on in the autumn, and recurring in spring; in 
infantile remittents it is a valuable remedy; the exacerbations 
are apt to occur at midnight, while the remissions appear in the 
morning, and are frequently accompanied by perspiration; there 
is early and almost comp]ete loss of muscular power; the pulse 
is large, full and quick, but not very hard; the face frequently 
has a crimson flush; there is intense frontal or occipital head- 



86 LECTURES ON FEVEES. 

ache; the head feels as big as a bushel; the tongue has a pale 
red color or else is covered with a yellowish white coat, and there 
is a slimy, bitter taste in the mouth. 

Bryonia, like gelsemium, is particularly indicated during the 
first week of the fever. It is adapted to pale complexioned, irri- 
table people. The exacerbations come on in the afternoon, and 
the remissions are not well marked. The headache is a painful 
pressure or tearing pain, relieved by lying down. Delirium, 
when it occurs, is usually about business affairs. The tongue i& 
thinly lined with mucus; the lips are parched, dry and cracked; 
the taste is flat and pasty; the vomiting is bilious in character, 
and occurs especially after drinking; the bowels are constipated, 
or else the discharges are diarrheic mixed with mucus, and of a 
deep brown color; the urine is either watery and clear, or else 
yellow with a yellow sediment. At times there is a marked dis- 
position to perspire. 

Eupatorium perf. is adapted to summer and autumn remit- 
tents that are attended by severe bilious symptoms ; there is in- 
tense occipital headache ; the tongue is coated with a thick, yel- 
low fur; vomiting occurs after drinking; there is fullness and 
tenderness in the hepatic region, with stitches and soreness on 
moving; the urine is scanty and dark colored. Aching in the 
bones with soreness of the flesh stands out as a prominent char- 
acteristic in remittent as well as intermittent fever. 

Ipecac may be needed when the gastric irritability is strongly 
marked; there is frontal headache, with disgust for food, espe- 
cially greasy food; nausea, with regurgitation of the ingesta; 
pale yellow color of the skin. 

Podophyllum renders excellent service when there is much 
intestinal irritation, and the febrile symptoms are strongly 
marked; the gastro-intestinal and hepatic symptoms predomi- 
nate; there is violent headache with excessive thirst; at times 
the headache alternates with diarrhea!; the evacuations are bil- 
ious in character, and there is a sense of fullness in the hepatic- 
region, with twisting pains; sallowness of the skin is a common 
attendant. 

Quinine will be of service at the commencement or at the 
close, when the remissions are well marked, and the fever as- 



TREATMENT OF REMITTENT EEVER. 87 

sumes a more or less distinctly intermittent type; it should be 
administered only during the remission; the pulse is frequently 
fluctuating in character ; it may be weak and thready during the 
remission, but full and compressible during the exacerbation; 
humming in the ears, with a sense of lightness across the ver- 
tex, or with a sense of rumbling through the occiput is a strong- 
indication for this remedy. 

Mercurius may prove useful in weak, delicate individuals, 
during the first week, when there is intense fever in the evening, 
most violent at midnight; the eyes and skin are yellow; the head- 
ache is worse on lying down; the taste, eructations and vomiting 
are all bitter; there is great desire for sour or piquant things; 
the tongue is lined with whitish mucus or a dirty yellow fur ; 
the evacuations from the bowels consist of large quantities of 
bile and mucus; the stomach and liver are sensitive to pressure; 
the urine is of a dark red color, as if mixed with blood. 

Nux vomica in irritable sanguine temperaments; it is mainly 
useful in the early stages; the patient is exceedingly irritable 
and wishes to be alone; the complexion is bright red with a yel- 
lowish tinge; the tongue is dry or coated, with bright red edges; 
adapted to men more than to women. 

Baptisia. — After the first week, for the early stages of the 
typhoid state; there is great nervous restlessness; the patient 
thinks the head is scattered over the bed; must toss about to get 
the x^ieces together; sensation as though there were a second self 
beside the patient in the bed; the headache is dull and stupefy- 
ing; the patient falls to sleep in the midst of an answer; the 
stupor resembles that of arnica and opium; the pulse is full and 
slow; the tongue is dry, with a brown streak down the center; 
the breath is foetid; sordes collect on the teeth; there is sinking 
at the stomach, and the patient can swallow only liquids ; the 
urine is high-colored, and the evacuations from the bowels are 
dark and offensive. 

Opium is indicated after the first week for the comatose state ; 
the stupor is complete; the respirations are stertorous; the 
stools are involuntary, and the face is dark, red and bloated. 

Mills tox. for coma, less pronounced than that of opium; the 
mental operations of the patient are slow and difficult; there is 



88 LECTURES ON FEVERS, 

restless sleep with, frightful dreams; the patient talks incoher- 
ently; the tongue is red at the tip in the shape of a triangle; 
the lips are dry and covered with brown crusts. 

Hyoseyamus for continuous delirium, illusions and hallucina- 
tions; the patient jumps out of bed and attempts to run away; 
he has no wants except thirst; there is muttering, with picking 
at the bedclothes, and at times subsultus tendinum; the tongue 
is red or brown, dry and cracked; the stools are involuntary. 

Belladonna for violent delirium with attempt to run away, to 
strike, bite or spit at attendants; there is a disposition to tear 
things to pieces; the symptoms point to brain congestion; the 
tongue is red at the margin and white in the centre. 

Arsenicum alb. may be needed for asthenic conditions in 
cases prolonged beyond the first week; weak, debilitated individ- 
uals often require arsenic during convalescence. 

Pulsatilla in fevers that run a slow course; it is suitable to 
women and children more than to men; the exacerbations take 
place in the evening; there is extreme aversion to animal food; 
the taste is bitter, and there is vomiting of mucus and bile; 
there is a whitish mucous coating on the tongue; the stomach 
and liver are sensitive to pressure; there is nightly diarrhoea, 
and the stools are watery or green like bile; pulsatilla will often 
relieve the excessive hunger that appears during convalescence. 

Crotalus and Phosphorus have been suggested for the intense 
icterus of remittents in southern latitudes. 

For further therapeutic indications I will refer you to the 
treatment of simple intermittent fever, as given in the previous 
lecture. 



LECTUEE VI 

Pernicious Fever. 

The third and last of the fevers caused solely by the presence 
in the human organism of the highly active malarial poison — 
the bacillus malarias — is Pernicious Malarial Fever. 

Definition. — It is a malignant and destructive malarial fever, 
characterized by special dangerous local affections in important 
organs. It may take the form of either an intermittent or a re- 
mittent. The pernicious attacks are of the tertian or quotidian 
type, and may occur at any time of the day or night. The per- 
nicious symptoms usually appear with the second or third 
paroxysm. Pernicious fever is not infrequently epidemic, and 
may assume one of the following varieties: the comatose, the 
delirious, the choleraic, the algid, the colliquative or the icteric. 
It tends to terminate fatally unless controlled before the third 
paroxysm. 

Synonyms. — It has been called Congestive fever, Malignant 
Intermittent, Malignant Remittent, Ardent fever, Jungle fever, 
and Tropical typhoid fever. 

History. — Pernicious fever is a rare disease in northern lati- 
tudes, but is quite common in the vicinity of the rice plantations 
of the southern states. It tends to prevail at certain epochs in 
warm and intensely malarial districts. Dr. Daniel Drake states 
that of the interior valley of North America, the regions in 
which it has most frequently prevailed are, " the level portions 
of Alabama, Mississippi and Louisiana, the southern shore of 
Lake Michigan from Chicago around to St. Joseph river, and 

89 



90 LECTUKES ON FEVEKS. 

of Lake St. Clair and Lake Erie, from Lake Huron to Lake 
Ontario, near the estuaries of the creeks and rivers." 

Etiology. — The exciting and predisposing causes of pernicious 
fever are similar to, but more intense than those of the other 
malarial fevers. A higher average range of temperature (65° 
Fahr.), than is necessary to produce either simple intermittent 
or simple remittent, is required for its development. 

Varieties. — The following well-marked and distinct forms 
may be mentioned: the comatose variety which is characterized 
by a tendency to coma; the delirious variety, characterized by 
a tendency to delirium; the choleraic variety, characterized by 
vomiting and purging with choleraic symptoms ; the algid variety, 
characterized by marble-like coldness of the cutaneous surface; 
the colliquative, characterized by profuse sweating; and the 
icteric which is characterized by acute jaundice. 

Clinical History. — Pernicious fever may begin abruptly, but 
generally its prodromes do not differ from those of the other 
malarial fevers. In the majority of the varieties the attack 
commences with a severe and prolonged chill. The paroxysm 
at this time may assume the form of either an intermittent or a 
remittent fever. One or two malarial paroxysms of the inter- 
mittent or remittent forms usually occur before the pernicious 
character of the fever appears. The type may be quotidian, 
tertian or quartan. Pernicious symptoms usually manifest 
themselves during the second or third paroxysm. In the quo- 
tidian type the pernicious attack occurs after the second or third 
day. In the tertian type it may not appear until the second 
week. A mild form of malarial fever may pass into a pernicious 
fever, by a progressive aggravation of symptoms; or a single 
paroxysm of not unusual severity may suddenly be followed by 
a pernicious one, terminating fatally with the second or third 
repetition. A numbness or coldness of the toes and fingers, 
continuing through the hot stage, while the trunk and head are 
in high fever heat is considered a characteristic sign of malig- 
nant remittent. At times a distinct initial chill may be followed 
by a condition clearly recognizable as one of the varieties of 
pernicious fever. One of the most common forms is the 

Comatose "Variety. — The only suggestive symptom of its ap- 
pearance is the presence of more headache, vertigo, apathy and 



DELIRIOUS VARIETY. 91 

disturbance of speech during either an intermittent or a remit- 
tent paroxysm, than ordinarily occurs in a simple form of mala- 
rial fever. After the chilly stage, and during either the hot 
stage of an intermittent or the exacerbation of a remittent, the 
patient passes into a state of stupor and unconsciousness. He 
lies upon his back. The eyes are closed and the pupils dilated. 
The face is hot and flushed. The skin is hot, dry, and jaundiced. 
The respirations are stertorous. The pulse may be either slow 
or frequent. The temperature reaches 105° Fahr. or 107° Fahr. 
If the case is to terminate fatally in this paroxysm the symp- 
toms of coma continue deeper, unconsciousness becomes com- 
plete, the heart power weakens, the pulse becomes irregular, and 
the patient dies. Usually, however, after the comatose symp- 
toms have continued for ten or twelve hours the patient returns- 
to consciousness in the midst of a profuse sweat. The headache 
and vertigo now disappear, and according to the type there may 
be a well-marked remission or a distinct intermission. At this 
stage the case may recover. But frequently with the next re- 
mittent exacerbation or the hot stage of an intermittent, all the 
symptoms return with increased severity, the stupor becomes- 
more marked, and the patient passes into fatal coma. Even 
when the patient lingers beyond the second paroxysm, he is apt 
to succumb, apparently from cerebral compression. 

Delirious Yariety. — The delirious variety is of less fre- 
quent occurrence than the one we have just described. As the 
patient passes into the exacerbation of a remittent or the hot 
stage of an intermittent, active delirium appears. This delirium 
differs from the ordinary delirium of malarial fevers in that it is 
violent in character, and is preceded by intense headache, ring- 
ing in the ears, and great restlessness. The face is either flushed 
or pale and sunken. The eyes are glistening and the conjunctivae 
injected. The pulse is full and hard, and the carotids beat vio- 
lently. The skin is hot and dry. The temperature rarely falls 
below 105° Fahr. and often reaches 107° Fahr. or 108° Fahr. This 
condition may last for hours. Somewhat suddenly the patient 
sinks into collapse, or passes gradually into deep coma from 
which he never awakens. In favorable cases the delirium be- 
comes less and less marked, profuse perspiration appears, and 
the patient falls into a prolonged sleep, from which he awakes 
to consciousness with headache and vertigo, but without the 



*92 LECTURES ON FEVEES. 

slightest recollection of what has taken place. A third or fourth 
repetition of the paroxysm is apt to prove fatal. At times epilep- 
tiform convulsions or tetanic spasms accompany or take the 
place of the delirium. 

Choleraic Yariety. — In the choleraic variety, which is of 
frequent occurrence, the patient after passing into the hot stage 
of an intermittent, or the exacerbation of a remittent, is sud- 
denly seized with choleraic symptoms. The vomiting is severe 
and yellowish in character, and the evacuations from the bowels 
are either watery and greenish, or resemble bloody water. The 
thirst is apt to be intense. There is a sense of weight and burn- 
ing in the epigastrium accompanied with cramps in the calves 
■of the legs, coldness of the skin and extreme restlessness. The 
pulse is almost imperceptible, and the respirations consist of a 
double inspiration followed by a double sighing expiration. Oc- 
casionally there is great dyspnoea, caused by overwhelming con- 
gestion of the lungs. As death approaches the pulse becomes 
hurried, irregular and fluttering. The expirations become more 
and more prolonged and sighing, and the skin becomes bathed 
in a cold, clammy perspiration. The duration of a fatal parox- 
ysm is from three to six hours. 

Algid Yariety. — The algid variety is as a rule confined to 
warm climates. It resembles somewhat the choleraic variety, 
and its progress is very insidious. It is characterized by mai- 
ble-like coldness of the body. As the patient enters the exac- 
erbation of a remittent or the hot stage of an intermittent, and 
notwithstanding he complains of burning heat and intense thirst, 
the surface of the body grows cold. The skin becomes pale and 
livid, and is covered with a cold sweat. The temperature in the 
axilla may be two or three degrees below the natural standard. 
The pulse is irregular, small and thready, and the respiration is 
superficial and slow; the breath is cold, and the voice is hoarse 
and feeble. The tongue is pale and cold, and the epigastric re- 
gion is sensitive to pressure; muco-bilious vomiting is a not 
uncommon symptom. The urine is scanty, dark-colored and of 
high specific gravity. The patient is conscious but apathetic, and 
wears the countenance of death. Usually the paroxysm marches 
steadily on, till death closes the scene. If recovery is to take 
place, the pulse returns in the wrist, the warmth comes to the 



COLLIQUATIVE VARIETY. 93 

surface, and the patient enters upon a slow convalescence. Not 
unfrequently a typhoid condition like that after cholera, super- 
venes. 

Colliquative Tariety. — In the colliquative variety a continu- 
ous sweat sets in at the close of the hot stage, accompanied by 
great prostration and coldness of the surface. This variety 
tends to end fatally after the second or third paroxysm. In 
such cases the pallor of the skin and mucous membrane becomes 
strongly marked; the heart's action grows more and more feeble; 
the respiration becomes labored, and the patient sweats to death. 

Icteric Tariety. — The icteric variety is generally endemic, 
and is oftener engrafted on an intermittent. It begins with a 
long-continued chill, attended with jaundice. The jaundice rap- 
idly deepens and the whole body assumes a saffron hue. Early 
in the attack there is intense nausea, with bilious vomiting and 
diarrhea; there is intense headache, and a feeling of numbness 
in the limbs ; the tongue is coated white or yellow, and the thirst 
is excessive; there is pain in the region of the liver and spleen; 
the pulse is small, frequent and hard; the urine is scanty and 
presents a deep red color. At the appearance of the hot 
stage all the symptoms grow more intense; the pulse becomes 
more frequent; the respirations become labored; the skin is 
hot, and the thirst intense; the temperature reaches 106° Fahr., 
or 107° Fahr.; the vomiting and diarrhea continue, and the 
urine becomes more and more scanty, and tenesmus appears. 
This stage lasts from three to five hours, and may terminate 
in death. If a fatal termination does not take place at this 
point, the patient passes into the sweating stage. The skin 
is now bathed in a profuse sweat, and under proper treatment 
the patient enters upon convalescence. In relapses, death gen- 
erally follows in the second or third paroxysm. 

ANALYSIS OF CHART. 

The Nervous System. — More or less complete coma charac- 
terizes the comatose variety. It sets in at the onset of the hot 
stage and may continue for a considerable time. Severe head- 
ache and vertigo are early symptoms of the delirious and icteric 
varieties. The delirium in the delirious variety varies from 
that of the lightest grade to the most violent maniacal spells. 
Eclampsia occurs mostly among children and puerperal women.. 



9i 



LECTURES ON FEVERS. 



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ALIMENTARY TRACT. 95 

Hydrophobic symptoms too, sometimes occur in the delirious 
variety in women. Convulsions frequently complicate the chol- 
eraic variety. In convalescence from the latter variety there is 
frequently wakefulness, with irritability of temper and partial 
loss of memory. The headache in the icteric variety is intense, 
and increases as the attack progresses. In unfavorable icteric 
cases the patient passes into a state of coma and dies. 

The Cutaneous Surface.— The skin is hot and dry, and the 
face flushed, in the comatose and delirious varieties; it is hot, 
dry, and intensely jaundiced in the icteric; and it is generally 
pale, cold and clammy in the choleraic; in the algid it is pale and 
livid, and has a marble-like coldness; in the colliquative it is 
covered with a profuse and frequently cold sweat. 

The Alimentary Tract. — The tongue is dry and often cov- 
ered with a fuliginous coat in the comatose variety. Thirst is 
great in all varieties. In the choleraic variety the symptoms re- 
semble those of cholera; vomiting is yellowish in character in 
the choleraic form, and is attended with burning thirst. In the 
algid variety the vomiting is muco-bilious in appearance, and 
in the icteric, decidedly bilious. In the choleraic and icteric 
varieties the intestinal symptoms are of decided importance, 
but in the algid they are only subordinate. Serious hemor- 
rhages fromthe stomach and bowels sometimes occur, and are 
apt to endanger the life of the patient. Dysenteric symptoms 
at times appear suddenly during a febrile attack, associated 
with cerebral manifestations. 

The Circulatory and Respiratory Systems. — In the coma- 
tose variety the pulse is sometimes fast and sometimes slow; 
and the respirations are rapid and stertorous. In the delirious 
variety the pulse is full and hard; when tetanic spasms occur it 
is irregular. In the choleraic form the pulse is small and hardly 
perceptible early in the attack, and irregular and thready towards 
the close. The respirations are shallow and as slow as ten per 
minute. As death approaches the pulse and respiration come to 
a complete stand-still. 

The Temperature. — In the comatose, delirious and icteric 
forms the thermometer usually shows a temperature of from 
105° Fahr. to 108° Fahr. In the algid variety the temperature 
is oftener below than above the natural standard; while in the 



96 LECTUEES ON FEVEES. 

choleraic and colliquative varieties it remains at a variable point 
above the normal until near the close of life. 

Morbid Anatomy. — The anatomical lesions of pernicious fever 
differ in degree, but are similar in kind to those which take place 
in intermittents and remittents. Free pigment and bacilli ( Fig. 
9) are found in the blood in larger quantities than in any of the 
other malarial fevers. The white corpuscles are diminished to 
one-half or one-third their normal number. And secondary con- 
gestion of the abdominal viscera is a decidedly prominent autop- 
sic phenomenon. 

Differential Diagnosis.— In the diagnosis of pernicious fever 
the character of the prevailing fever is of great importance. For 
when the pernicious form is prevailing in a locality the diagno- 
sis can easily be made ; Avhile in other cases, differentiation will 
be easy or difficult according to the type of fever. From simple 
intermittent or simple remittent, it can readily be distinguished 
after the first paroxysm, by the intensity of the symptoms and 
the general prostration. 

From apoplexy it can be diagnosed by remembering that hemi- 
plegia, which is a constant and prominent symptom of the 
former, is of rare occurrence in the latter. The coma and hemi- 
plegia of pernicious fever, when present, are usually preceded 
by intense febrile excitement, while in apoplexy their onset is 
sudden and without fever. 

From meningitis it may be diagnosed by the history of the 
case, and the sudden appearance of the coma. In meningitis, 
several days elapse before the delirium passes into coma. In 
pernicious fever one or two malarial paroxysms usually precede 
the attack of coma or delirium. In meningitis the pupil is di- 
lated during the coma, while in the comatose variety of perni- 
cious fever, it may be contracted, dilated, or normal. 

From cholera the choleraic and algid forms may be distin- 
guished by the early history of the endemic, the elevated tem- 
perature, and the character of the primary discharges. The 
choleraic discharges of pernicious fever are not profuse, and are 
characteristically preceded by one or two bloody discharges. 
The urine of cholera contains albumen, while that of pernicious 
fever does not; and finally, the blood of pernicious fever will be 
found to contain pigment, while that of cholera will not. 



PROGNOSIS, 97 

From yellow fever the icteric variety may be distinguished by 
the history of its development, and by the fact that when endemic 
it rarely troubles new-comers, but attacks those who have been 
for some time resident in the neighborhood. Yellow fever at- 
tacks by preference those who have recently moved into the in- 
fected district. The jaundice of pernicious fever appears earlier 
in the disease than that of yellow fever. Bloody urine, which is 
pathognomonic of the icteric variety of pernicious fever, rarely 
occurs in yellow fever. 

Prognosis. — The prognosis is, as a rule, unfavorable, for un- 
less the disease is controlled before the second or third attack, 
the case is apt to terminate fatally. Under appropriate treat- 
ment, however, statistics show that not more than from twelve to 
fifteen per cent. die. In all cases much will depend upon the 
character and stage of the epidemic. The ratio of mortality is 
invariably greater at the beginning than at the close of the epi- 
demic. The prognosis is always unfavorable when the paroxysms 
increase in severity and duration; the patient is apt to die in the 
third or fourth paroxysm. Distinct intermissions, however short, 
render the prognosis less grave. The tertian type of fever is 
the most favorable. Severe dysentery coming on at the end of a 
paroxysm is an unfavorable sign; and generally when the second 
or third paroxysm is protracted, and has such ominous accom- 
paniments as extreme restlessness and anxiety; epistaxis; de- 
lirium or coma; intense epigastric pain; numbness; red, scanty 
urine; vomiting and diarrhea; exhausting sweats, or feeble and 
almost imperceptible pulse ; the prognosis is very unfavorable, 
and the patient may die, not later than the fourth or fifth parox- 
ysm. Occasionally, as a paroxysm subsides, a continued fever 
with typhoid symptoms appears, and runs its course in ten or 
twelve days, terminating fatally. 

The most fatal cases of pernicious fever are the choleraic and 
the algid. The most likely to recover are the comatose, the de- 
lirious and the icteric. The death-rate is greatest among the in- 
temperate, and at the extremes of life. 

Treatment. — The treatment of pernicious fever must of ne- 
cessity be prompt, vigorous, and well-timed, for often the issue 
of life or death hangs on a single hour. Frequently, early in 
the disease the usual avenues for the introduction of remedies 



98 LECTUEES ON FEYEES. 

into the system are closed, as the patient is either unable to 
swallow or the stomach rejects everything as soon as taken. In 
such cases the hypodermatic administration of our remedies 
becomes an imperative necessity. And in general, the immedi- 
ate therapeutical effect of administering remedies in this man- 
ner is greater than by the usual 'per os method of adminis- 
tration. 

Hypodermatic Medication. — Five drops of the desired at- 
tenuation of the indicated remedy mixed with five drops of 
water, may be introduced beneath the skin into the subcutaneous 
cellular tissue, with the hypodermatic syringe. The silver or 
German silver syringe is the best, and preference should be 
given to a needle made of gold with a hardened or iridium point. 
The syringe may be charged with the required dose of solution 
by drawing the fluid up into the barrel by aspiration. Should 
air enter while the fluid is being drawn up, invert the syringe 
and push up the piston slowly until all air is expelled. From five 
to twenty minims of solution is the quantity usually adminis- 
tered at each hypodermatic injection. The spot commonly select- 
ed for the injection is the arm about the insertion of the deltoid. 
Care must always be taken to avoid puncturing a vein. "Where 
a patient is very timid or intolerant of pain, the sensibility of 
the skin may be lowered by applying a piece of cotton or cloth 
moistened with chloroform to the surface, and allowing it to re- 
main a few minutes. Preparatory to making the injection take 
up a loose fold of skin between the thumb and index finger of 
the left hand; then push the needle in with a quick and decided 
motion, at a right angle to the fold. As soon as the needle 
penetrates the skin all resistance to its further progress ceases. 
Pass the needle along in the subcutaneous tissue under the skin 
for from three-fourths of an inch to one inch. Make the injec- 
tion of the contained liquid slowly and finally withdraw the 
needle slowly, using pressure with the finger at point of punct- 
ure to prevent any escape of the solution. 

The various solutions of quinine when subcutaneously injected 
frequently excite considerable burning, and a zone of more or 
less redness for some distance around the puncture. This irri- 
tation can be readily allayed by applying a wet compress to the 
part for a short time. 

This method of medication inaugurated by Wood, of Edin- 



TBEATMENT. 99 

burgh, and introduced into this country by Dr. Forclyce Barker, 
of New York, in 1856, is, I am positive, destined to inaugurate a 
new era in the method of administration of homoeopathic rem- 
edies in sudden and dangerous types of disease, and perhaps 
also in chronic ailments. 

Principal Remedies. — Gelsemium^ etc. — Early in pernicious 
malarial fever, and before the pernicious character of the attack 
has been definitely stamped, gelsemium, or — according to the 
indications — one of the remedies mentioned in a former lecture 
■on the treatment of simple intermittent fever, will be indicated. 

Qninife bi-sulphas. — As soon, however, as the pernicious 
character of the paroxysm becomes apparent, and without regard 
to the stage of the paroxysm, administer either the acid or the 
neutral sulphate of quinine (which is soluble in water) hypoder- 
matically, in from one to two-grain doses every hour, until the 
time for the next paroxysm is passed. By so doing you will be 
very apt to prevent a return of the febrile movement, and thus 
save the life of your patient. Quinine, as a rule, in such cases, 
acts simply to prevent a recurrence of the much-dreaded parox- 
ysm, and hence whatever organic changes are produced by a 
long-continued action of the malarial poison, must be correct- 
ed by appropriate treatment subsequently, before the patient 
can be pronounced cured. 

As intercurrent and exceptionally as substitutive remedies, 
the following may be epitomized for further study: 

1. Comatose Variety. — Opium or rhus tox. 

2. Delirious Variety. — Hyoscyamus or belladonna. 

3. Choleraic Variety. — Ars. alb., vera! alb., podophyllum. 

4 Algid Variety. — Camphor, carbo veg., menyanthes, verat. 
alb. 

5. Colliquative Variety. — Cinchona, jaborandi, phosphorus. 

6. Icteric Variety. — Crotalus, eupat. perf., bryonia. 

The prophylactic and hygienic treatment is the same as for 
simple intermittent fever. Externally, direct heat may be ap- 
plied with hot-water bottles or hot sand bags laid along the 
spine. Stimulating enemas, and friction to the surface may also 
act as aids. In collapse a tablespoonf ul of brandy or whisky may 
be given every half hour or hour, until reaction occurs. As re- 
gards the use of stimulants at other times, the condition of the 
patient must be your guide. 



LECTUEE VII. 

Chronic Malarial Infection. 

Before leaving the diseases caused by that malarial poison,, 
the bacillus malariae, I must say something about Chronic Ma- 
larial Infection or Malarial Cachexia. 

Definition. — Chronic malarial infection, though a frequent 
sequel of acute malarial disease, may exist as a primary affection 
in intensely malarial regions, without any antecedent attacks of 
malarial fever. To illustrate : one individual may after frequent 
repetitions of, or incomplete recovery from intermittent or re- 
mittent fever, become anaemic, show on physical examination 
enlargement of the liver and spleen, and otherwise present the 
peculiar phenomena of chronic malarial infection; while another 
individual, after living for some time under malarial influence 
may present the same phenomena of chronic malarial infection, 
the anaemia, and the enlarged liver and spleen, though he may 
never have had a distinct paroxysm of malarial fever. 

Synonym. — Malarial Cachexia. 

Etiology. — Its etiology is the same as of malarial fevers in 
general. It may result from either a long-continued exposure 
in a slightly malarial district, or a short exposure in a strongly 
malarial region. The excessive use of quinine predisposes to 
malarial cachexia. 

Clinical History. — Patients suffering from chronic malarial 

infection generally complain of vertigo, with ringing in the ears, 

and disturbances of vision. They perspire copiously at night 

and on the slightest exertion. Pain and oppression at the epi- 

100 



MORBID ANATOMY. 101 

gastriuin is a frequent symptom. The tongue is covered with a 
yellowish-white coat; the mouth is dry and the taste metallic. 
There are nausea, anorexia, and frequently morning diarrhea. 
The sleep is usually disturbed; or if profound is unrefreshing. 
Many complain of wandering, dragging or burning pains in 
the back, along the sciatic nerve, and over the coccyx. The 
latter region is frequently painful on pressure. Others have 
stiffness of the muscles of the limbs and back, and suffer from 
fatigue and palpitation of the heart, on the slightest exertion. 
Anaesthesia of the outer surfaces of the thighs, numbness of the 
arms, and burning of the feet are quite common symptoms. 
While hemiplegia and neuralgia — especially of the fifth nerve — 
are among the occasional nervous manifestations. Patients suf- 
fering from long-continued malarial poisoning are very apt to 
become the victims of melancholia and hypochondriasis. The 
skin presents a yellowish pale hue. The urine is generally about 
normal, though at times it is profuse, and of low specific gravity. 
In severe attacks it may be scanty and dark colored. The tem- 
perature and pulse are usually normal, though the latter may be 
variable. The liver and spleen are enlarged, hard, and sensitive 
to pressure. In prolonged and severe cases, ascites is developed, 
hemorrhage from the nose occurs, and furuncles appear on the 
cutaneous surface. 

Morbid Anatomy. — The anatomical changes which take place 
in malarial cachexia resemble those of the severer types of ma- 
larial fever. The spleen is oftentimes enormously enlarged, and 
presents the changes of either simple hyperplasia or amyloid 
degeneration. Its surface is uneven, the capsule much thickened, 
and its substance proper is very rich in pigment matter. Simi- 
lar changes take place in the liver; and the kidneys are some- 
times extremely hyperasmic. Amyloid and fatty degeneration 
occasionally appears in the muscular tissue of the heart. The 
skin is always anasmic, and frequently there is oedema of the 
subcutaneous cellular tissue. An accumulation of fluid in the 
serous cavities often co-exists. Pigment granules and vacuolated 
red corpuscles are found in great numbers in the blood. In 
profound anaemia the number of red corpuscles may fall from 
iixe millions to less than one and one half millions per cubic 
millimeter of blood. 



102 LECTUEES ON FEVEBS. 

Differential Diagnosis. — The main characteristics of chronic 
malarial infection are: enlargement of the liver and spleen; a 
paroxysmal disposition in all the manifestations; the presence 
of free pigment in the blood in severe cases; vertigo with ring- 
ing in the ears; a disposition to catarrhal inflammation of the 
gastro-intestinal and respiratory tracts; a tendency to melancholy 
and hypochondriasis; attacks of neuralgia; anaemia, with palpi- 
tation of the heart; anasarca and general dropsy. 

And the occurrence of such a chain of symptoms in an indi- 
vidual who has repeatedly suffered from malarial fever parox- 
ysms, or has resided in a malarial district even though he may 
not have had a distinct malarial paroxysm, or who has been 
drugged or overdosed with quinine, is sufficiently suggestive 
of malarial cachexia. 

Prognosis. — As regards the prognosis we may say that the 
milder grades usually recover under appropriate treatment* 
while in the severe forms death may result from exhaustion 
with dropsical symptoms, Bright' s disease, lung affections, or 
from apoplexy due to pigment embolism. And generally, the 
greater the area of splenic and hepatic dullness the more un- 
favorable the prognosis. 

Treatment. — The patient must be immediately removed from 
the malarious district to an elevated, warm and mountainous re- 
gion. He must avoid getting wet, and must also observe all the 
hygienic regulations mentioned in the lecture on intermittent 
fever. The diet must be most nutritious, and should include a 
moderate allowance of light wines. Shower baths, and frequent 
cool baths with douches to the region of the liver and spleen, 
are very effective measures. 

Principal Remedies. — Arsenicum Alb. is the main remedy 
for chronic malarial infection, especially when quinine has been 
used to excess. It is particularly indicated when there is a ten- 
dency either to Bright' s disease or phthisis. The guiding symp- 
toms are : anaemia, with great debility, and oppression of breath- 
ing. Occasional symptoms are: spasms in the chest, violent 
pains in the stomach, and a left sided neuralgia associated with 
hemiplegia, also left sided. A decidedly dropsical tendency is 
always a strong indication for arsenic. 



DEXGUE. 103 

Ferrum. — Is adapted to cases where the anaemia is great and 
the debility extreme, provided oedema has not yet appeared. 
The stomach rejects all food, and there is palpitation of the 
heart. The breathing is difficult, and there is oppression of the 
chest as if some one pressed with the hand upon it. Particu- 
larly useful in weak, nervous individuals, and in delicate chlo- 
rotic women. 

Natruni Mur. — Is useful when the digestive organs are af- 
fected, and there is deficient nutrition. There is great emacia- 
tion and great prostration. The pulse is intermittent. The skin 
is dry and sallow: The urine is light and watery. And the 
patient is depressed, sad and melancholic. 

Lycopodium. — Is indicated when the digestive disturbances 
are due to hepatic influences, and when there is chronic gastro- 
intestinal catarrh. The face has a yellowish gray appearance. 
The hepatic region is sensitive to pressure. The smallest quantity 
of food produces satiety. Excessive fullness and distension of 
the abdomen from flatulence co-exists. 

Calcarea Carb. — Is useful in scrofulous individuals when 
there is a tendency to glandular swellings. The spleen is en- 
larged. The patient is unable to walk, perspires and has palpi- 
tation of the heart on the slightest exertion. The stools are 
white and undigested. At times there is alternate constipation 
and diarrhea. 

Finally, sulphur, carbo veg\, mere, bi-jod., phos., or some in- 
tercurrent remedy, will be needed to meet the various complica- 
tions that may occasionally arise. 

Dengue. 

I now come to the consideration of a fever, which, though not 
strictly malarial in character, has a right to be classed among 
miasmatic or infectious fevers. It is Dengue Feveb (pronounced 
dangay.) 

Definition. — Dengue is an acute febrile affection of short du- 
ration which appears as an epidemic in hot climates. It is due 
to an unknown external specific cause, and is characterized by 
two distinct and essentially different febrile paroxysms separated 
by a remission. It is accompanied by more or less intense ar- 
thritic pains, and occasionally by a cutaneous efflorescence re- 



104 LECTURES ON FEVERS. 

sembling that of scarlet fever. Dengue attacks all ages, and 
both sexes, and is an extremely painful disease. It may relapse, 
but seldom proves fatal. 

Synonyms. — Break-bone fever, dandy fever, three-day fever, 
stiff-necked fever, date fever, polka fever. 

History. — The earliest account of dengue fever, according to 
de Wilde dates from the year 1779. David Brylon, of Java, at 
that time described under the name knockel koorts (bone fever) 
an epidemic disease which prevailed in Batavia. The following 
year Dr. Bush described an epidemic which occurred in Phila- 
delphia. In 1818 the disease appeared at Lima, and in 1826 at 
Savannah. A general epidemic started at St. Thomas in the 
"West Indies, in 1827, and spread to this country in 1828, where 
it appeared at Pensacola, New Orleans, New York, Philadelphia 
and in some other cities. An epidemic prevailed in Brazil, in 
1846. In 1848, the fever again appeared, along with yellow 
fever, in New Orleans, Yicksburg and Mobile. Two years ] ater 
a general epidemic starting in Charleston, traversed the entire 
Southern States. In 1852, it appeared in Peru and was followed 
by yellow fever. For four consecutive years following 1864 it 
prevailed in Spain. It visited Arabia in 1871, and starting at 
Bombay and Cananore the next year, it spread through all India. 
In 1880 a mild epidemic prevailed at Charleston and in several 
of the Gulf cities. 

Etiology. — Dengue is a disease of warm climates, and 
promptly disappears upon the advent of frost. It prevails 
chiefly in cities, and travels mainly in the direction of the lines 
of human intercourse. The nature of the exciting cause of this 
disease is at present unknown. The morbific agent is, however, 
generally believed to be specific in character; and the infection 
is capable of being conveyed in clothing and merchandise from 
one part of the country to another. The period of incubation of 
the germ is from three to five days. Dengue is usually regarded 
as non-contagious. 

Clinical History. — The initiatory symptoms usually appear 
suddenly. Sometimes there is a prodromal stage of from one to 
three days' duration, characterized by slight chills, headache, a 
furred tongue, loss of appetite, and pains in the back and along, 
the spine. In the majority of cases the patient is seized with 



DURATION. 105 

intense frontal headache, photophobia, backache, and severe pain 
in the joints. Occasionally the first symptom is an acute pain 
in one of the small joints. The joints now swell rapidly and a 
painful stiffness of the muscles appears. The skin of the face 
and neck becomes flushed and turgid. The temperature may 
reach 107° Fahr. The pulse is full, hard and strong, occa- 
sionally intermittent, and ranging from 120 to 140 beats per min- 
ute. The stomach is extremely irritable, and there is burning 
pain in the epigastrium with nausea, and bilious vomiting. The 
lymphatic glands, beginning with the inguinal, frequently be- 
come enlarged and tender, and the epididymis is much swollen. 
A primary exanthem resembling the efflorescence of scarlet fever, 
but of a duller hue, and lasting only during the continuance of 
the fever now shows itself. This constitutes the stage of in- 
vasion. 

In from twelve hours to two, three or five days, the fever 
suddenly abates — frequently with the occurrence of critical 
symptoms such as profuse sweats, greenish, foul-smelling diar- 
rhea or epistaxis — leaving the patient feeble and prostrate. As 
the fever subsides the eruption disappears, the pains in the 
muscles and joints abate and moisture appears on the skin. The 
duration of this stage — the stage of remission — is from two to 
three days; occasionally it is so short as to be overlooked. 

The exacerbation, or second febrile paroxysm occurs on the 
fifth or sixth day of the disease. Its onset is announced by the 
re-appearance of the acute symptoms. The temperature again 
rises, but the fever is remittent rather than continued in char- 
acter. Simultaneously with the elevation of temperature, a 
scarlatinal, erythematous, or roseola-like eruption makes its ap- 
pearance. This exanthem shows itself first upon the palms of 
the hands or upon the soles of the feet, and soon spreads over 
the entire body. It is attended by a troublesome itching, and 
after remaining from a few hours to two or three days, vanishes 
in a furfuraceous desquamation. The fever now gradually sub- 
sides, and the acute symptoms disappear, and the patient passes 
on to convalescence. 

Duration. — Dengue is a self -limited 'affection, appears fre- 
quently in distinct types, and has an average duration of about 
eight days. Relapses after an interval of two or three weeks 
frequently occur. These are always milder than the primary at- 



106 LECTURES ON FEVERS. 

tack, and closely resemble an attack of articular rheumatism. 
Complications seldom arise, and sequels are rare. Dr. Forrest, 
of Charleston, mentions excessive and obstinate prostration, 
sleeplessness, anaemia, neuralgia, boils and carbuncles, aphonia, 
bronchial catarrh, rheumatism, and temporary paralysis of the 
lower limbs, as possible sequels. 

ANALYSIS OF CHART. 

The Nervous System. — The headache, during the fever es- 
pecially, involves the forehead and temples. Restlessness and 
sleeplessness are generally present during the first and third 
stages. Sometimes nocturnal delirium occurs. In children con- 
vulsions are prone to appear, and occasionally cause a fatal 
termination. 

The Cutaneous System. — In the majority of cases a primary 
and a secondary exanthem occurs. The primary exanthem is 
not as constant a manifestation as is the secondary exanthem. 
"When present it appears and disappears simultaneously with 
the fever. The secondary exanthem is as a rule always encount- 
ered. It may assume various and occasionally mixed forms. In 
children, blotches resembling urticaria are frequently seen, and 
at times considerable swelling of the skin attends the eruption. 
As the fever subsides bran-like desquamation usually takes 
place. In exceptional cases the desquamation may be flaky in- 
stead of furfuraceous. In very rare cases the mucous membrane 
of the throat, mouth, and nose becomes inflamed and ulcerated. 
During convalescence, boils and extensive subcutaneous ab- 
scesses occasionally occur. 

The Glandular System. — The parotids are frequently swollen, 
and the glands about the groin and axilla become transiently 
enlarged. In severe cases along with enlargement of the epi- 
didymis, serous effusion may take place into the tunica vagina- 
lis. 

The Digestive System. — Thirst and anorexia accompany the 
whole course of the disease. The taste is disordered and the 
tongue becomes coated with a white or greenish-yellow fur. The 
patient complains of nausea with pain in the epigastrium, and 
occasionally vomiting. In the early stages there is constipation 
with a tendency to hepatic torpor or slight congestion. Later in 



CHART. 

GHAET V.— Dengue. 



107 



Duration : 


Eight days. 


Initial 
symptoms : 


Intense headache. Acute pain in small joints. 


Stages : 


Invasion, 


Remis'ion, 


Exacerbation. 


Time: 


2 to 3 days, 


12 hours 
to 3 days 


2 to 3 days. 


Nervous 

system : 


Intense frontal headache. 
Sleeplessness. 


CO 

CO » 
J CO 

o_ 

CD CJ 
CO 


Headache. 
Extreme nervousness. 


Eyes : 


Staring expression. 
Photophobia. 


Conjunctivitis. 
Photophobia. 


Temperature : 


106° to 108°, 


105° to 107°. 


Pulse: 


120 to 110, 


120 to 140. 


Respiration : 


28 to 30 per minute, 


23 to 26 per minute. 


Eruption : 


Primary exanthem, 
scarlatinal. 


Secondary exanthem, 
scarlatinal, erythematous 

orroseola-iike. 
Branny desquamation. 


Glands : 


Glandular swellings. 

especially of inguinal glands, 

and epididymis. 


Glandular swellings. Boils. 


Extremities : 


Boring pain, and stiffness in 
joints and limbs, 


Pains and stiffness, 
Loss of strength in legs. 


Tongue: 


Coated, silver-white or 
greenish-yellow, 


Thickly coated. 


Stomach : 


Thirst. Nausea. 
Bilious vomiting. 


Nausea. Rarely vomiting. 


Bowels : 


Constipated, 


Frequently diarrhea. 


Urine: 


Scanty and dark, 
sp. gr. high, 


Augmnt 'd. 


Scanty and dark. 


Prognosis : 


Always favorable. 


Convale s- 
cenee: 


Frequently protracted, 

with extreme debility, stiffness and soreness of the joints, 

and g'reat emaciation. 


Duration of 
epidemic: 


From two to seven months. 



the disease the constipation may disappear, after a crisis marked 
by diarrhea. 

The Extremities.— The affection of the joints and limbs at- 
tacks large and small joints alike. The joints of the hand, foot 
and knee are first attacked, then the spine, and lastly the joints 



108 LECTURES ON EEVERS, 

of the elbow and shoulder. In severe cases all the joints be- 
come involved. The peculiarities of gait and attitude caused 
by interference with the natural movements of the limbs have 
given to this disease many of its synonyms. The affected joints 
are swollen, red, immobile, painful and highly sensitive to the 
touch. The muscles are stiffened and sore, and the tendons are 
somewhat swollen. The pains are characterized as rheumatic or 
rheumatoid, and tend to pass from one joint to another with 
great rapidity. 

After the second paroxysm the joint disturbance gradually 
disappears. Ofttimes it lingers for several weeks and may be- 
come localized. Extreme debility and loss of muscular power, 
more particularly in the legs, may continue far into the convales- 
cence. 

Differential Diagnosis. — In the first paroxysm, or stage of 
invasion, this fever may be confounded with acute articular rheu- 
matism. In the second paroxysm, or stage of exacerbation, it 
bears a striking likeness to scarlet fever or measles. In its gen- 
eral course it strongly resembles spirillum or relapsing fever. 
From rheumatism it may be distinguished by the cutaneous 
eruption and the epidemic character and rapid spread of the 
disease. From scarlet fever it may be distinguished by the per- 
sistency of the rheumatic and neuralgic pains, as well as by the 
natural course of the affection. And from relapsing fever it 
may be differentiated by the eruption, the character of the re- 
missions, and the absence of spirilla in the blood. 

Prognosis. — The prognosis is always very favorable. A fatal 
termination is an exceptional occurrence, and appears mostly at 
the extremes of life. 

Treatment. — Prophylaxis. — Eigid quarantine of infected dis- 
tricts and the complete isolation of patients are absolutely neces- 
sary to prevent the rapid spread of dengue. 

Diet. — The diet should be most nutritious, and frequent feed- 
ing will prove very beneficial. Hot drinks during the fever are 
grateful to the patient and tend to excite free perspiration, a 
state greatly to be desired. During convalescence alcoholic 
stimulants should be given. 

Principal Remedies. — In the first stage, aconite either alone 
or in alternation with belladonna or bryonia has been found 



LEADING INDICATIONS. 109 

most beneficial. In the second stage, arsenicnm alb., bryonia, 
rbus ven., nuxvom., puis., or sulphur will be most frequently in- 
dicated. In the third stage, gelsemium takes the place filled by 
aconite in the first stage. During convalescence either cinchona 
or nux yom. may be needed. Hot mustard foot-baths at the on- 
set of the fever, are highly recommended. The annoying itch- 
ing which attends desquamation at the close of the second 
paroxysm may be relieved by the application of a one per cent, 
solution of carbolic acid, while the stiffness and soreness of 
the muscles and joints which tend to linger and thus protract 
convalescence, will be best treated by either massage or the mild 
galvanic current. 

Leading Indications — Aconite. — In the first paroxysm when 
there is high fever, great restlessness and anxiety, full, hard, 
quick pulse; pain in the forehead and temples; hot, pale-red 
swelling of the joints. It is followed well by belladonna. 

Belladonna. — Especially adapted to dengue in children, and 
when either the congestive or throat symptoms predominate. 
Eyes are red and glistening; staring pupils. Eed, shining swell- 
ing of the joints. Pains running from the affected joints along 
the limbs like electric shocks. 

Bryonia. — Neuralgic and rheumatic pains, worse on motion. 
Faintish streaky redness of the joints. Pain in the eyes when 
moving them. Loss of appetite, white coated tongue, fullness 
and oppression in the pit of the stomach and bowels. 

Eupatorinm perf. — Has been highly recommended in the first 
stage. The bones ache as if broken. Painful soreness of both 
wrists as if broken. The tongue is thickly coated yellow, and 
there is thirst with vomiting after drinking. The region of the 
liver is sore on pressure, and there is great tenderness in the 
epigastrium. 

'Gelsemium. — In the stage of exacerbation, and in asthenic 
types of the fever generally. There is intense muscular pros- 
tration. Great languor and drowsiness. Heavy suffused eyes, 
and an eruption resembling measles. Giddiness with loss of 
sight. Bruised pains in the muscles, general rheumatic symp- 
toms. The tongue is coated whitish or yellowish, and there is a 
sticky feeling in the mouth. 



110 LECTURES ON FEVEBS. 

Hyoscyamus. — For the extreme nervousness and sleeplessness. 

Mercurius. — Is occasionally indicated when there is swelling 
•of the glands of the neck. The pains in the joints are tearing, 
worse at night and in warmth of the bed. Diarrhea especially 
toward evening. 

Pulsatilla. — Is often indicated during the remission, and 
when the pains are relieved by a critical discharge. The pains 
are of a drawing, tearing character and frequently shift from 
one part to another. All symptoms are worse toward evening, 
and at night in a warm room ; better from changing position and 
uncovering the affected parts. The tongue is moist and coated, 
and there is a bad taste in the mouth. Diarrheaic stools at night. 
Urticaria. Epididymitis. 

Rims Venenata. — Is one of the most useful and oftenest in- 
dicated remedies, after aconite. The guiding symptoms are 
those of the skin and mucous membrane. There may be excess- 
ive parotid inflammation, especially on the left side. The ax- 
illary glands are inflamed and swollen. The eruption is dark- 
colored. There are drawing, tearing pains in the joints with a 
sense of lameness and formication in the affected parts. The 
pains are worse during rest and when commencing to move; they 
are relieved by continued motion and by dry external warmth. 
Jerking, tearing pains in the elbow and wrist joints. Paralysis 
of the lower extremities. 



LECTUEE Till. 

Typlio-Malarial Fever. 

We now come to the study of typlio-naalarial fever, a disease 
that has attracted much attention since the late civil war. Its 
relations are somewhat peculiar, in that it presents many ele- 
ments in common with typhoid fever, and many which ally it to 
remittent fever. 

Definition. — It is a miasmatic disease due to the combined 
action of a malarial and a septic poison, and may appear in two 
at times distinct, and at other times, imperceptibly blended 
types. The first, or malarial type, is ushered in by a distinct 
chill, and is characterized by a rapid rise of temperature, a ten- 
dency to tertian periodicity, predominance of gastric symptoms, 
abdominal tenderness and diarrhea, and the presence of free pig- 
ment in the blood; it usually terminates in recovery, amend- 
ment gradually taking place between the 10th and 20 th days. 
The second, or septic type, is marked by a more decided typhoid 
tendency, more hepatic tenderness and splenic enlargement, an 
icteroid hue of the skin, dark foetid evacuations, more abdominal 
tenderness, and an increased amount of free pigment in the 
blood. In fatal cases, at the close of the second week, the pa- 
tient passes into a state of stupor, followed by coma and death. 
In cases that are to recover, at the end of the second week the 
tongue begins to clean, and the gastric and intestinal symptoms 
gradually subside. Convalescence is slow and tedious. After 
death, pathological lesions are found, which closely resemble 
those of typhoid fever on the one hand, and remittent fever on 
the other. Typho-malarial fever is non-contagious. -jjl 



112 LECTURES ON FEVERS. 

Synonyms.— It has been variously termed entero-miasmatic 
fever, remitto-typhus, camp fever, and Chickahominy fever. 

History. — Typho-malarial fever is most prevalent in malarial 
districts, and more especially during the autumnal season. It 
prevailed largely among the United States troops during the 
war of the rebellion, and was the great scourge of the army of 
the Potomac in the Peninsular campaign of 1862. 

Etiology. — The true nature of the poison of typho-malarial 
fever is unknown. It is however generally believed to have a 
double origin ; part of the morbific agent being supplied by mala- 
ria, and part by some other poison, septic in character, of which 
sewer-gas is the type. "With such a dual character this morbific 
agent may give rise to two types of fever, according as one or 
the other element predominates. Hence we speak of a septic 
and of a malarial type of typho-malarial fever. Oftentimes the 
distinguishing lines between these two types are not sharply de- 
fined, and frequently the symptoms of the one become almost 
imperceptibly mingled with those of the other. 

Typho-malarial fever is non-contagious. It is a disease solely 
of malarial districts, and prevails only when anti-hygienic con- 
ditions, such as over-crowding and bad sewerage exist to favor 
the development of the septic element. 

Clinical History. — The clinical history embraces a descrip- 
tion, first, of that type in which the malarial element prevails, 
and then of the form in which the septic element is predomi- 
nant. 

The Malarial Type. — The premonitory symptoms of this type, 
when present, are those of malaise, headache, loss of appetite, 
and wandering pains in the back and limbs. At this stage the. 
countenance frequently presents a yellowish or clay-colored 
aspect. 

The attack is usually ushered in by a distinct chill or general 
coldness, which bears a marked resemblance to the chill of sim- 
ple remittent fever. Following the chill, which varies in dura- 
tion from half an hour to an hour, active febrile symptoms ap- 
pear, and the temperature rises in a few hours to 103° Fahr. or 
104° Fahr. The excretions are all checked, and the skin becomes 
hot, dry and harsh. The pulse reaches 100 and is full and forcible. 



CLINICAL HISTOEY. 113 

The patient is restless, sleepless and incapable of mental exertion. 
Between sleeping and waking there may be slight delirium. 
The tongue is at first pale and flabby, then moist and covered 
with a whitish yellow fur. After a time it becomes dry and red 
and sordes may collect upon the teeth and lips. As the fever 
advances, nausea, vomiting, and epigastric tenderness become 
more marked. In many instances diarrhea precedes the initial 
chill; in the majority of cases it is present during the fever. 
Early in the disease there is abdominal tenderness, especially in 
the right iliac fossa. A decided tendency to tertian periodicity 
exists throughout the entire course of the fever. 

In fatal cases, as the patient enters the second week, or some- 
times later, symptoms of the typhoid slate appear; the prostra- 
tion rapidly increases; the pulse becomes frequent and feeble; 
the patient passes into a state of stupor; the tongue becomes 
dry and fissured, and is protruded with difficulty; the faeces and 
urine escape involuntarily, or the urine may be retained; and 
there may besubsultus tendinum and carphologia; gradually the 
stupor deepens into coma, and death takes place. 

In favorable cases the symptoms begin to ameliorate between 
the tenth and twentieth days ; the temperature steadily declines 
and the pulse becomes less frequent and fuller; the nervous 
symptoms improve; the tongue becomes clean, the thirst dimin- 
ishes, and the appetite returns; the abdominal symptoms sub_ 
side, and the patient enters upon a protracted convalescence. 

The Septic Type. — The initial symptoms of this type are those 
of general malaise, with headache, and pains in the back and 
limbs. Usually the febrile symptoms are ushered in with either 
a distinct chill, or a complete intermittent or remittent paroxysm ; 
following the chill, the temperature rise may be either sudden 
or gradual; it may reach 104° Fahr. or 105° Fahr. within twenty- 
four hours, or not until the eighth or tenth day. A tertian or 
quartan periodicity runs through the whole course of the disease. 
The pulse is full and frequent, and averages about 100 beats per 
minute during the early days of the fever; later, it becomes 
small and compressible and may range from 110 to 130 per min- 
ute. The headache becomes continuous, and as the fever pro- 
gresses gives place to a muttering delirium; the sleep is much 
disturbed, and there is great lack of mental vigor; occasionally 



114 LECTURES ON EEVEES. 

subsultus tendinum, and carphologia appear. The skin becomes 
dry and assumes a bronzed or jaundiced hue. The lips are dry 
and parched. The tongue is at first, moist, swollen and covered 
with a whitish fur; after a time it becomes dry, cracked and 
fissured. The urine grows scanty and high-colored. The stools, 
which tend to increase in frequency as the disease advances, are 
fetid, watery, and generally dark-colored. The abdomen is rarely 
distended; frequently, it is somewhat retracted; it is tender to 
pressure, particularly over the ileo-csecal region. 

In fatal cases as the patient reaches the second or third week, 
the symptoms closely resemble those of fatal typhoid fever; the 
pulse now becomes irregular and feeble ; the prostration steadily 
increases; the faeces and urine escape involuntarily or the urine 
is retained, and the patient passes into a state of stupor, which 
deepens into coma, and ends in death. 

In favorable cases improvement sets in about the twelfth or 
fourteenth day; the tongue becomes moist and begins to clean, 
gradually, from the edges to the center. A renewal of the fever 
symptoms is sure to occur, when, after the coating is thrown off 
in flakes, the tongue assumes a beefy red appearance, and again 
becomes dry and brown. As recovery progresses, the abdominal 
symptoms, with the exception of the diarrhea begin to subside; 
the pulse becomes slower and the temperature range steadily 
approaches the normal; the appetite improves; the strength 
gradually returns; and the patient enters upon a tedious conva- 
lescence, liable to be disturbed by complications and sequels. 

Typho-malarial fever, when occurring amongst the poorly fed 
and illy clad, who live in badly ventilated apartments, frequently 
takes on a low type and is attended by neuralgic and arthritic 
pains in various parts of the body, and at times displays a 
hemorrhagic tendency, marked by bleedings from the gums and 
mucous surfaces. In such cases death may be caused during 
the course of the disease by hemorrhage from the mucous sur- 
faces; and even after convalescence appears to be established an 
uncontrollable diarrhea may set in, and by exhaustion lead to a 
fatal result. 

Complications. — The most frequent complication of typho- 
malarial fever is inflammation of the respiratory organs; it may 
take the form of either a troublesome bronchitis, or a catarrhal 



ANALYSIS OF CHAET. 115 

pneumonia. So often is it the complicating lesion, that when- 
ever any sudden variation in temperature occurs during the 
course of the fever, lung trouble may be suspected, and a 
thorough physical exploration of the chest should be instituted. 
Serious abdominal complications, such as intestinal perforation, 
peritonitis and hemorrhage, are rarely met with in this fever. 

Duration. — The average duration of typho-malarial fever is 
from three to four weeks. The malarial variety is always shorter 
than the septic. Kelapses may occur at any period during con- 
valescence. 

ANALYSIS OF CHART. 

The Nervous System— Headache is one of the earlier and 
more constant symptoms. It often precedes the ushering-in 
chill. It is most severe in the first week, and passes into mut- 
tering delirium as the fever progresses. In many instances the 
delirium, if mild, occurs only at night, and in all cases it is more 
marked during the night time. In advanced stages of se- 
vere cases, subsultus terdinum, picking at the bed-clothes^ 
and vague graspings in the air are observed. Neuralgic and 
arthritic pains in the back and limbs are commonly present in 
cases modified by anti-hygienic surroundings. With deferves- 
cence there is great lack of mental vigor, and a tendency to men- 
tal sluggishness. 

The Digestive Tract. — The tongue at first is somewhat 
swollen, and covered with a thin, whitish fur. As the typhoid 
state increases, it becomes % dry, brown, and fissured. In grave 
cases sordes collect upon the teeth and lips. The appetite is 
greatly disturbed from the start, and is wholly lost when the 
tongue becomes brown and dry. In mild cases when the tongue 
retains its moisture, the loss of appetite may be only partial. 
Nausea and vomiting, and epigastric tenderness are present in a 
greater or less degree in all cases. The matters vomited usually 
consist of food, or of gastric mucus stained green with bile. 
Diarrhea is a common symptom and may occur at any period. 
It is seldom excessive before the second or third week. The 
stools are generally fetid, watery, and dark-colored. At times 
they are of a dark clay color. With the diarrhea there is more 
or less abdominal tenderness, especially in the right iliac region. 
Tympanites is seldom marked. Hemorrhage from the bowels 



116 



LECTUEES ON FEVEES. 

CHAET VI.—Typho-Malarial Fever. 



Nature : 


Non-contagious. 


Etiology: 


A dual morbific agent— (septic and malarial.) 


Period: 


First week, 


Second week, 1 Third week, 
(and exceptionally the (and exceptionally the 
third ) 1 fourth.) 


Initial 

symptoms : 


A chill or malarial paroxysm. 


Nervous 
system : 


Headache, 

Restlessness, 
Sleeplessness, 


Active or muttering 

delirium. Subsultus ten- 

dinum. Carphologia, 


Delirium disappears 

or passes into 

stupor and coma. 


Tongue : 


Swollen. 

Red papillae White 

coating. 


Dry and brown, 


Moist as convales- 
cence sets in . 


Stomach : 


Anorexia, 
Nausea. Vomiting, 


Epigastric tenderness. 


Subsidence 
of symptoms. 


^Bowels : 


Fetid, watery, dark evacuations; 
at times constipation. 


Abdomen: 


Slight tenderness in right iliac fossa. Retraction. 
Tympanites rare. 


Pulse: 


100. Full and forcible, 


110 to 130 
Small, compressible, 


Slower or faster, 


Temperature: 


Gradual or sud'n rise, Remissions every 
103° to 105°, 2d o r 3d day, 


Gradually approaches 
the normal. 


Pace: 


Waxy, clay-colored or yellowish. 


Skin: 


Bronzed, or icteric hue. 


Blood: 


Free pigment granules. 


Urine : 


Scanty, dark-colored, turbid. 


Increased. 


Liver: 


Enlarged. Hepatic tenderness. 


Spleen : 


Enlarged. Pigmented. Dark. 


Duration: 


Two to four weeks. 


Complications : 




Bronchitis and catarrhal pneumonia. 



occasionally occurs and may cause death from exhaustion. When 
diarrhea follows t]ie subsidence of the fever, and is uncontroll- 
able, there is danger of its leading to a fatal termination. He- 
patic tenderness is a well-marked and early symptom. Enlarge- 
ment of the spleen takes place as the fever progresses. The 
amount of enlargement is apt to be greater than in typhoid 
fever. 



MORBID ANATOMY. 117 

The Temperature.— The temperature rise is apt to be sud- 
den, and may reach 103° Fahr. or 104° Fahr. in a few hours. In 
some cases the rise is gradual, the maximum not being reached 
before the tenth day. Well-marked forenoon remissions appear 
every second or third day. 

The Pulse. — The increase in the frequency of the pulse cor- 
responds to the rise in temperature. It is less frequent in the 
morning than in the evening. During the first week it is full, 
and rarely exceeds 100. During the second and third weeks, it 
Is small and compressible, and ranges from 110 to 130. During 
the third week it gradually diminishes in frequency. In severe 
cases it is apt to be frequent. And as a general rule a steady 
range above 120 renders the prognosis somewhat unfavorable. 

The Cutaneous Surface. — The skin becomes dry and harsh, 
and assumes a bronzed hue shortly after the onset of the fever. 

Morbid Anatomy. — The pathological changes of typho-mala- 
xial fever are similar to those which occur in typhoid fever, and 
in malarial fever. The liver is increased in size, and its cut sur- 
face presents an appearance analogous to that of nutmeg liver. 
In many cases it is softened, and upon microscopical examination 
shows free fat, and more or less brown pigment in the hepatic 
cells. The spleen is enlarged, softened and pigmented, and on 
section is of an almost black color. The changes in the kidneys 
are those of hyperemia and are most marked in the cortical sub- 
stance. The heart is soft and of a pale, yellowish, or faded-leaf 
color; the softening is due to a granular degeneration of the 
muscular fibres. The blood is dark colored, and contains free- 
pigment granules. The intestinal changes of typho-malarial 
fever, like those of typhoid fever center in and around the agmi- 
nate and solitary glands of the ileum. The pathological pro- 
cesses commence at the lower extremity of the ileum and extend 
upwards. The glands may be found in different stages of de- 
generation. In the earlier stages they are enlarged and infil- 
trated by an excessive proliferation of cellular elements, and by 
a deposit of black pigment, and the mucous membrane presents 
~the appearance of catarrhal inflammation. Peyer's patches be- 
come thickened, and there is a gradual elevation of the mucous 
membrane surrounding the enlarged follicles. After a variable 
length of time, ulcers appear at the summit of the follicles. 



118 LECTUEES ON FEVEES. 

Tliese ulcers differ from those of typhoid fever, in that they pre- 
sent ragged, irregular and extremely undermined edges, and are 
more or less pigmented. They may involve only a single folli- 
cle, or they may extend into the submucous tissue and attain the 
size of from half an inch to an inch in diameter. The enlarged 
patches rarely present the umbilical depression prior to ulceration 
so common in typhoid fever. Intestinal perforation as a result of 
ulceration is an accident seldom met with in typho-malarial fever. 
The mesenteric glands will usually be found more or less en- 
larged and pigmented. Small ulcers are occasionally met with 
in the stomach and large intestines. And if scurvy complicates 
either type, ulcerative changes similar to those found in chronic 
malarial dysentery, are liable to occur. 

Differential Diagnosis. — The septic type of typho-malarial 
fever is liable to be confounded with typhoid fever, and the 
malarial type with simple remittent fever. The onset of 
typho-malarial fever however, is apt to be sudden and is 
marked by a distinct chill, while that of typhoid fever is in- 
sidious, and is attended only by a chilly sensation. The tem- 
perature rise in typho-malarial fever is sudden, and follows, 
no typical range, while in typhoid fever the typical range 
during the first week is characteristic. In typho-malarial 
fever there is a distinct periodicity in febrile action which 
does not appear in typhoid fever. Typho-malarial fever has. 
no characteristic eruption, while typhoid fever has a rose- 
colored eruption, which makes its appearance about the seventh 
day. The individual rose-colored spots of typhoid fever last 
only three days, while the eruption of typho-malarial fever, 
when present, remains visible throughout the whole course of 
the fever. In typho-malarial fever the skin has an icteroid 
hue, and there is marked hepatic tenderness, and extensive- 
splenic enlargement. The stools of typho-malarial fever are 
non-infectious, while those of typhoid fever are infectious. 
The blood in typho-malarial fever contains free pigment, while 
that of typhoid fever rarely does. 

From simple remittent fever, typho-malarial fever may be 
differentiated by the early appearance of the enteric symptoms 
in the latter. 

Prom typhus fever, it may be diagnosed by the presence of 



PRINCIPAL REMEDIES. 119 

abdominal symptoms which are absent in typlms, and "by the ab- 
sence of the mulberry-rash of typhus. 

From yellow fever, it may be distinguished by the fact that the 
range of temperature is lower in the former than in the latter. 
Yellow fever is a portable disease, typho-malarial fever is en- 
demic, and non-portable. In yellow fever the short duration of 
the disease, the remission on the third or fourth day, the circum- 
orbital pain, the red and watery eye, the peculiar color of the 
skin, the projectile vomiting, the black vomit, the gaseous 
pulse, the absence of diarrhea, and the presence of albumen in 
the urine, are symptoms sufficiently diagnostic. 

Prognosis. — The prognosis varies with the habits and social 
condition of the patient. The average ratio of mortality is from 
five to ten per cent. The septic type is more fatal than the ma- 
larial type. Drunkenness and anti-hygienic surroundings lessen 
the chances for recovery. The prognosis should always be 
guarded when there is a continued high temperature, a frequent, 
feeble, fluttering pulse, a profuse diarrhea, a dry, red and fissured 
tongue, great drowsiness and a tendency to stupor and coma, and 
especially when, during the third week of the fever, capillary 
bronchitis or pneumonia supervenes. 

Treatment. — The preventive treatment consists in the first 
place in entire removal from anti-hygienic surroundings, such as 
over-crowding, defective sewerage or faulty drainage ; and in 
the second place, in well regulated and nutritious feeding, and 
in the strict observance of the laws of health. You will fre- 
quently find baptisia, 1st dil. administered morning and evening, 
act as a valuable prophylactic in localities where typho-malarial 
fever prevails. 

Principal Remedies. — The therapeutics of this form of fever 
will vary with the type of the fever, and the peculiarities of each 
individual case. The septic type will frequently be aborted by 
the timely use of baptisia; and the malarial type can be materi- 
ally shortened by the administration of gelsemium during the 
stage of invasion. When these remedies fail to cut short the 
disease before the end of the first week, bryonia will generally 
be needed. And if in from two to four days no improvement 
appears, bryonia should give place to rhus tox., and especially if 
there is diarrhea and the stools are black-brown, and involun- 



120 LECTUEES ON FEVERS. 

tary. Arsenicum follows well after rhus tox., and is adapted to 
the second and third weeks of the f ever. For hepatic disturb- 
ances mercurius will frequently be needed. Hyoscyamus, stra- 
monium, or belladonna, will prove a valuable intercurrent 
remedy, when stupor or furious delirium supervenes. Arnica 
is indicated as an intercurrent when there are involuntary 
discharges of stool and urine. When the pneumonic symp- 
toms are strongly marked, and have not been relieved by bry- 
onia, and there is a violent dry racking cough, Phosphorus 
often helps. " Stools, black like coffee dregs," is an additional 
indication for phosphorus. Tart, emet will be of service when 
there are mucous rales, and threatened oedema of the lungs. A 
tardy convalescence calls for either Phosphoric acid or cinchona. 

Baptisia. — Corresponds with the first 7 or 10 days of thefever ? 
and is our nearest similimum for the congestive and catarrhal 
changes occurring in the intestinal tract during this period. It 
has a marked action to clean the tongue, and causes an early re- 
turn of appetite. A soreness on lying, and a sense of being all 
to pieces, are characteristics. Typho-malarial fever, not typhoid 
fever, is the fever that is " broken up " by the administration of 
Baptisia; as typhoid fever will run its typical course in spite of 
treatment. 

Bryonia. — Stands next to baptisia. It has a longer action 
than baptisia, and corresponds to forms that run a mild or mod- 
erately intense course. It frequently cuts the fever short at the 
end of the second week if not before. Moderately severe cases 
frequently need no other remedy. Nightly delirium does not in 
any stage contra-indicate, but on the contrary is an additional 
indication for, bryonia. 

Rhus tox. — Is indicated for a more intense character of the 
disease, and when there is excessive reactive endeavor with in- 
sufficient reactive power. It corresponds to all the stages, but 
seldom cuts the fever short. A red triangle at' the tip of the 
tongue is characteristic. 

Arsenicum all). — Follows Khus well, and especially if the 
adynamic state is strongly marked. Marked remissions of the 
fever are quite characteristic of this remedy. Weak and debili- 
tated individuals frequently respond, as if by magic, to the 
action of arsenic. 



HYGIENIC AND DIETETIC TKEATMENT. 121 

(jelsemium. — Is specially useful in the early stages of the 
malarial type of this form of fever. There is great nervous rest- 
lessness, and muscular weakness. The puke is full and soft, but 
not very rapid. The tongue is moist and coated with a white 
fur. After the end of the first week either arsenicum or bryonia 
will be needed to complete the cure. 

Mercurius. — Isoftener indicated in typho-malarial fever, than 
in typhoid fever. An icteroid hue of the skin, hepatic tender- 
ness, and a painful sensibility of the abdomen, are among the 
more prominent symptoms. Mercurius is never indicated when 
there is delirium and the tongue becomes dry. 

Phosphorus. — Is the remedy for the lung complications, and 
when colliquative diarrhea occurs as a sequel. 

Phosphoric Acid. — "Will frequently prove useful in cases 
complicated with scurvy ; and when convalescence is protracted 
and there is great prostration. 

Additional indications for these, and for other less important 
remedies for typho-malarial fever, have already been mentioned 
in a general way in connection with the treatment of malarial 
fevers. They will, however, be specially considered when we 
come to speak of the treatment of typhoid fever. 

HYGIENIC AND DIETETIC TREATMENT. 

The sick room should be large and well ventilated. The tem- 
perature of the apartment should be maintained at from 60° Fahr. 
to 70° Fahr. Mental quietude is extremely important. If the 
fever runs high the cold bath, as recommended by some of our 
writers, if used at all, should be used with extreme caution, for 
typho-malarial fever patients do not always stand this treatment 
well. 

The best drink is pure water. But wine and water, lemonade, 
iced tea with lemon juice, or thin barley water are all grateful. 

The diet should be restricted and for the most part liquid. It 
should be administered with regularity, and as often as every 
hour or two when there is great prostration. Milk occupies the 
first place as a food. It may be given either raw or boiled. But- 
ter-milk or koumyss may be given occasionally as a substitute 
for milk. Beef tea or chicken broth containing a little barley is 
very nutritious and is oftentimes quite palatable to the patient. 



122 LECTURES ON FEVERS. 

The addition of two or three grains of pepsin* to each cupful 
of milk or broth facilitates digestion. Alcoholic stimulants are 
unnecessary unless there are signs of heart failure. In the ma- 
jority of cases they are not needed before the end of the second 
week. The best effects are obtained from claret or champagne. 
"Whisky or brandy may be given in the form of milk punch or 
commingled with water. During convalescence the diet should 
be restricted to milk, koumyss, eggs, custards, farinaceous foods, 
and animal broths. At the end of a week solid food and par- 
ticularly meat may be taken. Milk punch, egg-nog, and wine 
are often of service during convalescence. And as early as 
practicable a brief journey to the sea-shore, or at least a change 
of climate and scenery will aid materially in bringing about a 
rapid restoration to health. 

*Hawley's saccharated pepsin is the best. Fairchild's essence of pepsin 
stands next. 



LECTURE IX, 

Hay Fever, 

Hay fever may be justly classed among the miasmatic dis- 
eases, as it is caused by the action of an agent which originates 
outside the susceptible organism, and floats in the atmosphere, 
and cannot be conveyed from one susceptible person to another. 

Definition. — It may be defined as a miasmatic disease caused 
mainly by the action of the pollen of plants and grasses upon 
the organs of respiration, It is confined almost wholly to the 
educated classes, and occurs mostly between the ages of 15 
and 45. It appears in two forms; the catarrhal, and the astli medic. 
The catarrhal variety is characterized by the discharge of thin 
watery serum from the nostrils, by violent attacks of sneezing, 
by redness and swelling of the eyelids, by severe lachrymation, 
and by a slight burning feeling in the mucous membrane of the 
mouth and fauces. The asthmatic variety is in addition con- 
stantly accompanied by laryngo-bronchial catarrh. Its asthma 
is peculiar in that it occurs mostly in the day time, and varies 
from a moderate cough to intense and distressing dyspnoea. 
Hay fever usually attacks, its victims annually, either in June, 
August or September; and the earlier the attack the milder its 
course. It appears suddenly, remains about six weeks, and de- 
parts as suddenly as it came, leaving behind no perceptible ef- 
fects. 

Synonyms. — It has been variously named, Hose cold, June 
cold, Bostock's catarrh, Pollen catarrh, Pollen asthma, Hay 
asthma, Eye asthma, and Catarrhus sestivus. 

History,, — Hay fever had its birth-place in England. It was 

123 



124 LECTURES ON EEYERS. 

first described by Bostock, himself a victim, in 1819. In 1854 
Phoebus of Giessen, gave an analysis of 300 cases. Dr. Wyman, 
of Harvard University, in 1872 described the disease under the 
name of autumnal catarrh. And the following year Dr. Beard 
published his treatise on hay fever or summer catarrh. More 
recently Dr. Blackiey has given to the profession the important 
results of his experimental studies, extending over a period of 
ten years. Hay fever is especially prevalent in England, and is 
rapidly becoming a common disease in the northern sections of 
this country. 

Etiology. — The causes of this affection are of two kinds, 
predisposing and exciting — 

1. The predisposing causes: 

Hay fever is a disease of the upper classes of society, and phy- 
sicians are frequent victims. It attacks only people predisposed 
to it, and mainly such as are of the Anglo-Saxon race. Nervous 
temperaments are particularly susceptible. The degree of sus- 
ceptibility will vary in different individuals, and a given pollen 
may be highly irritating with one person and comparatively 
mild with another. The susceptibility becomes more marked in 
each succeeding year. The disease attacks individuals under 
forty years of age only; and prevails more among males than 
females. Hereditary tendency is supposed by some to play an 
important part in its causation. 

2. The exciting causes: 

Hay fever appears usually in early summer and mid-summer. 
It is caused by the presence of the pollen of flowering plants in 
the atmosphere, and its irritant action on the respiratory mucous 
membrane of susceptible individuals. The time of flowering of 
hay grass, Indian corn, and especially of the rag-weed (which 
begins the latter part of August, and continues through Sep- 
tember) is most favorable to its development. The pollen be- 
longs to the non-coherent class, and as it floats in the air is dry 
and shrivelled. In the dry as well as in the fresh state it is ca- 
pable of producing all the symptoms of this distressing malady. 
The pollen of plants that have flowered prematurely does not 
possess the activity of that which is generated later. Tempera- 
ture exercises an important influence upon the production as 
well as activity of pollen. A low temperature below a certain 
point not only lessens the quantity thrown off, but also causes 



CLINICAL HISTOEY. . 125 

that which is generated to act with less vigor. Rainy weather 
notably diminishes the quantity. Hence hay fever patients 
suffer less in cold and wet summers than in warm and com- 
paratively dry seasons. 

The disturbance caused by the pollen is due partly to its me- 
chanical effect and partly to the physiological action of its granu- 
lar matter. Blackley thinks that the sneezing and discharge of 
serum of the first stage, are due to the mechanical changes in- 
cident to the development of the pollen tube, from the influence 
of the moisture of the nasal passages on the pollen, and its pene- 
tration into the mucous follicle. And the swelling caused by 
the effusion of fluid into the submucous cellular tissue is due 
to the presence of some substance or quality in the granular 
matter. 

Hay fever attacks are more violent in the country than in the 
city, and in the open air than in-doors. In this country the 
disease prevails mostly throughout the North, while nearly the 
whole of the Southern States is entirely free from it. 

Varieties. — It may exist in either of two forms — the catarrhal 
and the asthmatic — and each form is made up of three stages — 

1. The stage of development : which lasts from one hour to a 
few days. 

2. The paroxysmal stage: of three or four weeks' duration. 

3. The stage of convalescence: of short duration. 

Both varieties may exist together, or either one of them may 
appear alone. 

Clinical History. — The catarrhal form runs its course with 
little or no pain, and no important symptoms. The first symp- 
tom is generally a mild or severe itching in the fauces, Eustachian 
tubes, and the nostrils. Violent attacks of sneezing soon occur, 
followed by a discharge of thin watery serum from the nostrils. 
The nasal mucous membrane swells more or less rapidly, accord- 
ing to the amount of pollen in the respired air. Frequently the 
swelling is so great that the nares are closed. If the patient 
takes the recumbent position on the side, the swelling subsides 
in the nasal passage which is uppermost, since the cedematous 
effusion gravitates towards the lowest part. As the height of 
the hay season approaches, the paroxysms of sneezing, which 
have hitherto occurred mostly during the day, are apt to appear 



126 LECTURES ON FEVERS. 

also at night. After a time the sensibility of the highly swollen 
Schneiderian membrane becomes lessened. Later the membrane 
becomes thickened, and ultimately even purulent. The eye 
symptoms generally follow the nasal symptoms and are initiated 
by an attack of itching. As the season progresses the itching 
becomes more troublesome, and is frequently attended by a 
slight burning sensation. Occasionally shooting neuralgic pains 
are felt in the back part of the orbit and in the eyeball. In 
severe attacks the eyelids become ©edematous, and slight che- 
mosis is established. When the disease is fully developed the 
lachrymal canals and nasal ducts become almost entirely closed 
by the swelling of the submucous tissue. The discharge is at 
first thin and watery, then thicker, and in exceptional cases, 
purulent. The mucous membrane of the fauces and mouth is 
not as sensitive to the action of the pollen, as that of the nares. 
The pharynx is the seat of an itching and slight burning or 
pricking sensation. The itching is apt to be severe in the hard 
palate, the upper part of the pharynx and in the Eustachian 
tubes. Sometimes there is slight deafness, which occasionally 
tends to linger. Rarely there is hoarseness and a moderate 
cough. The chemosis and the oedema of the eyelids are gener- 
ally the last symptoms to disappear. 

The asthmatic form is, constantly accompanied by laryngo- 
bronchial catarrh, and in many of its symptoms closely resem- 
bles ordinary asthma. After the coryza and eye symptoms of 
the ordinary catarrhal form have been in existence a variable 
length of time, a difficulty of breathing appears. Sometimes 
however they will come together. The first symptom of an 
asthmatic attack is a sense of tightness and weight across the 
-chest. The difficulty of breathing is greatest during the night, 
but may be somewhat severe during the after part of the day, 
from the increased inhalation of pollen. Patients frequently 
complain of a feeling as of a band passing around the head above 
the eyes. After the catarrhal symptoms have existed for some 
time a cough appears. In some cases this cough is moderate, 
and is attended with some expectoration and slight dyspnoea; 
whilst in others it is dry and spasmodic, and is accompanied by 
marked asthmatic symptoms, with great dyspnoea and anxiety. 
The sputum is at first thin and frothy, later it m ay be purulent. 
In the declining stage of the disease there is a marked tendency 
for the discharge from the nostrils to become puriform. 



ANALYSIS OF CHART. 127 

In some instances, after a long and violent attack of sneezing, 
a slight fever is discernible. The pulse will then be frequent 
and full, the face flushed, and the respiration more rapid. This 
temporary feverish state is apt to end with a slight shivering, 
and a cold perspiration. Active exercise produces marked ag- 
gravation of all symptoms. Hence hay fever patients should 
keep on hand a generous supply of " fatigue material." 

After these symptoms have prevailed with greater or lesser 
intensity for three, four or six weeks, they begin to decline, and 
the patient enters convalescence. The recovery is usually rapid. 
The asthma departs suddenly, often in a single night, and the 
catarrhal symptoms vanish within two or three days. Frequent- 
ly the attacks are prolonged by renewed exposure to the in- 
fluence of pollen. 

ANALYSIS OF CHART. 

The Schneideriau Membrane. — In the earlier years of the 
disease, the action of the pollen is most marked in the nasal pas- 
sages. In the first stages of the disorder the fits of sneezing 
are not very long nor very severe, but later on they become so 
violent that for the time being the patient loses all self-control. 
He may sneeze twenty or thirty times in succession. Occasion- 
ally a profuse cold sweat will break out at the termination of 
each sneezing attack. The frequency of the sneezing paroxysms 
and the profuseness of the discharge of thin watery serum de- 
pend largely though not entirely, upon the quantity of pollen 
inhaled. After a time the alse nasi, as well as the mucous mem- 
brane lining the nasal passages, become inflamed and tender. 
As the disease progresses the discharge from the nostrils tends 
to become inspissated and puriform, especially early in the 
morning. 

The Eyes. — In most cases the irritation of the eyes follows 
that of the nasal passages, but if the wind is moderately strong, 
and in consequence thereof an extra quantity of pollen is 
brought into contact with the conjunctiva, it may appear earlier 
than the nasal symptoms. The first symptom is usually a troub- 
lesome itching. The swelling and occlusion of the lachrymal 
canals and nasal ducts, is caused in part by the irritation of the 
pollen which passes down the duct from the eyeball, and in part 
by that which is deposited in the nostril during respiration. The 



128 



LECTURES ON FEVERS. 

CHAET YIL— Hay Fever. 



Etiology : 


The pollen of plants and grasses. 


Time of ap- 
pearance: 


Erom July to September. 


Catarrhal Form. 


Stage : 


Stage of develop- 
ment. 


Paroxysmal stage. 


Stage of convales- 
cence. 


Duration: 


1 hour to 48 hours. 


3 to 4 weeks. 


12 hours to 32 hours. 


Nose: 


Itching. 

Sneezing in day-time. 

"Watery discharge. 


Swelling of mucous mem. 

Sneezing, day and night. 

Discharge, watery & thin, 

or else inspissated or 

puriform. 


Discharge at times 
puriform. 


Eyes: 


Itching and 
Lachrymation. 


Itching. Lachrymation . 

Neuralgic pains. 
(Edemaof lids. Chemosis. 


(Edema of lids and 
Chemosis. 


Mouth and 
fauces: 


Itching. 


Itching and slight burn'g. 




Ears: 


Itching. 


Slight dullness of hearing. 


Skin: 


At times a papular eruption is present. 


Asthmatic Form. 


Stage: 


Stage of develop- 
ment. 


Paroxysmal stage. 


Stage of convales- 
cence. 


Duration: 


1 hour to 48 hours. 


3 to 4 weeks. 


1 to 3 days. 


Nose, eyes, 

month 
and fauces: 


Symptoms same as in the catarrhal form. 


Larynx and 
trachea : 


Difficulty of 
breathing. 


Slight hoarseness. 


Slight obstruction 
of breathing. 


Wheezing. Rales. 
.. Cough, moderate or 
severe. 
Dyspnoea. 


Bronchi. 


Sputum : 


Thin, frothy, and containing granules. 


Ears: 


Slight deafness. Tinnitus aurium. 


Head: 


Feeling as of a band around the head above the eyes. 



DIFFERENTIAL DIAGNOSIS. 129 

itching and burning in the eyes cause a constant desire on the 
part of the patient to rub them. Cheinosis is only produced 
when there is a maximum quantity of pollen in the air, or when 
the patient is very sensitive to its action. Photophobia is occa- 
sionally added to the discomfort of the temporary invalid. The 
discharges from the eye are at first thin and watery, later they 
become inspissated. In ordinary hay-fever attacks, the mischief 
does not extend beyond the sub-conjunctival cellular tissue. 

The Mouth and Fauces.— The itching sensations in the mouth 
and fauces usually follow those of the eyes and nasal passages. 
They are seldom very strongly marked, and deglutition is rarely 
interfered with. At times there is a sense of dryness and ob- 
struction in the throat on awaking in the morning. 

The Bespiratory Tract. — Chest symptoms appear only in 
the asthmatic variety. The first asthmatic attack usually comes 
on in the day-time, after the coryza and lachrymation have be- 
come well-marked. And when asthma once appears it is apt to 
continue with more or less severity during the whole of the hay 
season. In some cases the dyspnoea becomes so urgent that the 
patient is unable to lie down. A scanty expectoration is usually 
accompanied by more dyspnoea than a copious one. The dyspnoea 
is due to the tumefaction of the bronchial mucous membrane, and 
the consequent interference with the free transmission of air, 
which causes imperfect oxygenation of the blood. Emphysema 
of the lungs, which is a common sequel of ordinary asthma is 
rarely, if ever, found to follow hay asthma. 

Differential Diagnosis. — From ordinary sporadic catarrhs, 
the catarrhal variety of hay fever may be distinguished by its 
returning annually at the regular season, and by the attacks be- 
ing more violent during a residence in the vicinity of fields of 
flowering grasses and cereals. Flakes of epithelium which are 
frequently found in the effused fluid in severe attacks of com- 
mon coryza, are seldom if ever found in hay fever. 

From common asthma the asthmatic variety may be easily 
differentiated. The first attack of the season of hay asthma ap- 
pears in the day-time, after exposure to the influence of pollen. 
The first attack of ordinary asthma comes on at night, and fre- 
quently after a dyspeptic siege. A primary attack of ordinary 
asthma generally comes on in-doors, that of hay asthma often 



130 LECTUKES ON FEVERS. 

comes on in the open air. The paroxysms of ordinary asthma 
are intermittent in character, while those of hay asthma are apt 
to be remittent. The coryza of common asthma is never as se- 
vere as that of hay asthma. Hay asthma is a disease of the sum- 
mer months, while common asthma is most prevalent during the 
winter season. 

Prognosis. — The prognosis is always favorable, though the 
disease tends to return in succeeding years. 

Treatment. — Prophylaxis. — The preventive treatment con- 
sists mainly in the removal of the patient beyond the reach of 
pollen. High altitudes and the open ocean are most free from 
it. Hence a residence at such places as Deer Park, or Jefferson, 
or Paul Smith's in the Adirondacks, or a sea voyage is an un- 
failing remedy. Many would-be victims escape by a timely re- 
moval to the sea-coast. Such patients are quite comfortable and 
enjoy immunity from the attacks, as long as the sea breeze blows, 
but are more or less affected as soon as a land breeze appears. 

Sulphur, if taken before the hay season sets in, will to a limited 
extent modify the attacks, but the Arsenicum iodide is our best 
prophylactic remedy. Dr. Sebastian, of Texas, has experienced 
good results from the wearing of a thick veil during the hay 
fever season. In men, the respirator, alluded to in the lectures 
on malaria, might be worn instead of the veil. 

The following localities and places of escape from the domain 
of pollen, are mentioned by Dr. Morril "Wyman : The Glen, 
Gorham, Kandolph, Jefferson, Whitefield, Bethlehem village, 
the "White Mountain Notch, and the Twin Mountain House, in 
New Hampshire; Mount Mansfield, in Vermont; the Adiron- 
dacks; the Island of Mackinaw; the Lake Superior region; the 
Allegheny Mountains at Oakland, and the Iron Mountain. A 
certain immunity is experienced at Fire Island, off the coast of 
Long Island, and at Beach Haven on the Jersey coast. 

From this locality (Chicago), patients frequently go to places 
in Northern Michigan, Wisconsin, or Minnesota, during the hay 
fever season. English physicians often send their patients to 
the Highlands in Scotland, or to the mountainous districts in 
Wales. 

Palliative Treatment. — Nasal douches, or spray inhalations 
of a solution of glyceroborate of calcium, dry inhalations of an 



LEADING INDICATIONS. 131 

iodine and ether solution, or insufflations of Mercurius corr., 
1st cent, trit, or Argentum nitricurn, 1st dec. trit., may prove 
highly serviceable during the attack. A weak galvanic current 
will greatly relieve the frontal headache. The irritation of the 
eyes and face may be allayed by bathing the parts several times 
per day, in hot and cold water, alternately. Voluntary preven- 
tion of sneezing will greatly benefit mild cases. Pressing firmly 
•on the upper lip, when the inclination is felt, will frequently ar- 
rest a sneezing paroxysm. Arseniate of Quinine and Turkish 
baths are occasionally of service for the prostration. 

Leading Indications. — Change of climate is the most effect- 
ive remedy. Patients unable to go away during the hay fever 
season, may however be greatly benefited, and at times cured, 
by internal treatment. 

Aconite. — In plethoric, active individuals, and when there is 
febrile disturbance, photophobia, and a feeling as of sand in 
the eyes. Violent sneezing with slight discharge of blood from 
nose and larynx. Loud, dry, hard cough, before or after sneezing. 
Numbness in the back part of the throat. After mental excite- 
ment. 

Allium cepa. — Burning, acrid discharge, with violent laryn- 
geal cough. Smarting of the eyes with violent sneezing. Must 
take a long breath, and then sneeze accordingly. Worse in the 
evening and in a warm room. Symptoms begin on the left side 
and travel to the right. 

Ammonium mur. — Burning in the eyes, and lachrymation at 
night. Bawness and soreness in the fauces. Is obliged to clear 
the throat frequently. Burning in small sjwts in the chest. Itch- 
ing in the larynx. Dyspnoea on moving and when lying. 

Aralia racemosa. — Smarting soreness of posterior nares and 
alee nasi. Frequent sneezing. Warm salty taste in the mouth. 
Dry, wheezing respiration, with rapidly increasing dyspnoea. 
Suffocative feeling on lying down. Loud whistling, worse during 
inspiration. Excessive sensitiveness to slight changes of tem- 
perature. 

Arsenicum alb. — Is the best remedy for a watery, acrid, ex- 
coriating discharge, with thirst, burning sensations about the 
nose, eyes ; throat and chest. Great restlessness and anxiety, and 



132 LECTURES ON FEVERS. 

extreme debility. Dyspnoea, especially when paroxysms are- 
worse from midnight till day-break. Pain extending from the 
small of the back to the thighs, when coughing. Symptoms 
worse from the least bodily exertion, and from a change of 
weather. 

Arsenicum iodide. — In individuals of pale, delicate complex- 
ion, and when there is a tendency to glandular enlargement. 
Puffiness of the lids. Burning sensations in the nostrils and 
throat. Discharge irritating and corrosive. Worse in the morn- 
ing, or after meals. 

Arum triph. — Sneezing, with acrid, fluent discharge ; excoria- 
tion of nostril and upper lip. All the symptoms are worse at 
night. 

Asarum. — Fluent discharge with deafness. Sensation as if 
the ears were plugged up with something. 

Badiaga. — Spasmodic cough with sneezing and lachrymation. 
Yellow viscid mucus flies from the mouth and nostrils during the 
paroxysm. 

Belladonna. — In plethoric individuals, and especially in chil- 
dren and females of an irritable disposition. Dryness of the 
mouth and throat. Offensive smell, after blowing the nose, as of 
herring-brine. The cough causes sharp cutting pains in the 
head. The paroxysms occur in the afternoon and evening, and 
are accompanied by a sensation as of dust in the lungs. All the 
symptoms are aggravated by exposure to the least current of cold 
air. 

Camphor. — The 1st attenuation of camphor, if taken as soon 
as the first symptoms appear, will frequently produce a marked 
amelioration. 

Cyclamen. — When there is a great deal of sneezing, with rheu- 
matic pains in the ears and head. Loss of smell. 

Euphrasia. — When the force of the disease is concentrated on 
the eye and its surroundings. In the early stages, as soon as the 
watery discharge and sneezing begin. When there is severe itch- 
ing and burning at the margin of the eyelids, with swelling of 
the parts. Dry tickling cough in the day-time, better from eat- 
ing, and drinking small quantities. After windy weather. 



LEADING INDICATIONS. 133 

Gelsemium. — Malaise. Mucous discharge from the nose and 
throat. Feverishness. Pain in the throat running up to the ear 
when swallowing. Sensation as of a stream of scalding water 
passing from the throat up into the left nostril. Hardness of 
hearing. Sighing respiration. 

Grindelia robusta. — In the asthmatic variety. Inhalation 
easy but expectoration difficult. Accumulation of tenacious mu- 
cus in the small bronchi. Excessive nervousness. 

Ipecacuanha. — In the asthmatic form. Long continued, ex- 
haustive fits of coughing, with suffocative spells. Gasps for air 
at an open window. Cough causes gagging and vomiting, which 
brings relief. Worse from the least motion. 

Kali bich. — Adapted to light-haired individuals. Burning 
of mucous membrane, extending from the throat into the nostrils. 
Aching pain at the root of the nose, with fluent, acrid discharge. 
Pinching pain across the bridge of the nose, relieved by hard 
pressure. Hoarseness and oppressed breathing. Wheezing 
cough with expectoration of tough, stringy mucus. Cough ex- 
cited by eating or drinking. Sore, ulcerated spots on the mucous 
membrane. Foul tongue. Complete loss of smell. Has been 
successfully used as a prophylactic. 

Kali hyd. — Swelling and redness of the nose, and oedema of 
the eyelids. Burning, corroding discharge from the nostrils. 
Painful hammering in the frontal region. Oppression of breath- 
ing with pain in both eyes. Hoarseness. Wheezing and rat- 
tling in the chest. White, frothy expectoration. Choking sen- 
sation on awaking. 

Lachesis.— Excessive sneezing, with copious discharge of 
watery mucus. Swelling and soreness of the nares and lips. 
Feeling of constriction in the throat and chest. Sensitiveness 
■of the larynx with a feeling of suffocation when touched. Op- 
pressive pain in the chest, as if full of wind. Dyspnoea worse 
after sleep, and after eating. All symptoms are worse during 
the day, or on falling asleep. May be used to remove excessive 
susceptibility. 

Mercurins. — Frequent sneezing, with swelling, redness, and 
soreness of the nose. Acrid excoriating discharge. Mucus has 
-an unpleasant odor. Inclination to vomit during coughing. Vio- 
lent night cough. Pain in the limbs. 



134 LECTUEES ON FEVERS. 

Nitric acid. — Sticking sensation behind the sternum, as from 
splinters. Malar bones are sore. Useful in the latter stages 
when the discharge from the nostrils is thick and puriform. 

Nux YOm. — Feeling of dryness in the posterior nares. The 
nose is obstructed in the day-time, but discharges in the evening. 

Opium. — When the asthmatic attacks come on during sleep,, 
and are apt to be followed by violent fits of dry, racking cough, 
relieved by drinking. 

Pulsatilla. — When the discharge has considerable consistence 
and there are alternate stoppage and discharge. The discharge is 
more copious in the open air. In hysterical individuals, or when 
accompanied by deranged menstruation. Sudden prostration 
with palpitation of the heart. Dizziness on rising from a seat. 
Copious vomiting of mucus. Constant chilliness. Loss of 
smell. Aversion to milk and fat food. 

Rumex crispus. — Sore feeling in the eyes. Violent and 
rapid sneezing. Fluent discharge with painful irritation in the 
nostrils. Dryness in the posterior nares. 

Sabadilla. — Violent sneezing. Copious watery discharge from 
the nose and eyes. Severe frontal pain. Redness of the eyelids. 
Lachrymation in the open air, and when looking at a bright 
light. Dryness of the mouth, without thirst. Muffled cough, 
worse on lying clown. Chilliness with heat of the face. Pain- 
ful lameness in the knee joints. Is highly recommended by Dr. 
Bayes. 

Sangniiiaria. — Frequent sneezing, worse on the right side, 
aggravated by odors. Watery acrid discharge. Smell in nose 
like roasted onion. Severe pain at the root of the nose, and in 
the frontal sinuses, with dry cough, and pain in the chest. 
Burning dryness of the mouth and throat, not relieved by drink- 
ing. Pressure and heaviness in the upper part of the chest, 
with difficulty of breathing. Soreness and burning in the lungs. 
Wheezing, whistling cough, and finally diarrhea which relieves 
the cough. Cough worse at night. Passage of flatus with the 
cough. Bad smelling sputa. Circumscribed redness of the 
cheeks. 

Sticta pill. — Incessant sneezing, with burning in the eyes. 
Splitting frontal headache with a feeling of fullness at the root 






LEADING INDICATIONS. 135 

of the nose. Excessive dryness of the nasal mucous membrane. 
Dryness of the throat, worse at night. The secretions dry rap- 
idly, forming scabs difficult to dislodge. Tickling in the bronchi 
and larynx. Incessant, racking cough, provoked by inspiration. 

Sulphur. — Sneezing on first awaking in the- morning or on 
lying down in the evening. Profuse perspiration after sneezing 
or coughing. Continued oppression of breathing between the 
paroxysms. Soreness and ulceration of the nostrils. Rough- 
ness and dryness of the throat. Burning sensation in the 
trachea. Expectoration of a tenacious bronchial mucus. 

Tartar eraet. — Great rattling of mucus, with oppressed 
breathing. Stoppage of the nose, alternating with fluid dis- 
charge. Epistaxis followed by fluid discharge with sneezing. 
Loss of taste and smell. Rheumatic aching in the muscles and 
joints. 

Ambrosia art. has been used with good success in varied 
types of hay fever. 

For additional indications, consult Lecture xvii, on the treat- 
ment of influenza. 



LECTUEE X. 

Typhoid Fever. 

At my last lecture I completed the description of the first 
class of fevers — the miasmatic. To-day I will commence the 
history of the second class — the miasmatic-contagious. The 
typical disease of this class is Typhoid Fever. 

Definition. — It may be defined as an acute endemic fever, 
lasting about twenty-eight days or longer, due to a morbific 
agent — supposed to be a rod-shaped bacterium — associated with 
certain forms of decomposing animal matter. It is character- 
ized by a gradual approach, marked by malaise, anorexia, dull 
headache, epistaxis and a bronchial cough; a red or dry and 
brown tongue ; tympanites and abdominal tenderness; diarrhea 
with "pea-soup" discharges; rose-colored spots, after the sev- 
enth day, appearing in successive crops; stupor and delirium; 
late prostration and protracted convalescence. Constant lesions 
of the solitary and agminate glands of the ileum, with enlarge- 
ment of the spleen and mesenteric glands, are found upon ex- 
amination after death. 

Synonyms. — Nervous fever. Enteric fever. Autumnal fever. 
Infantile remittent fever. Gastric fever. Mucous fever. Keel- 
tongue fever. Endemic fever. Pythogenic fever. Abdomi- 
nal typhus. 

History. — -According to traditions typhoid fever has prevailed 

from earliest times. Hippocrates is credited as having narrated 

its symptoms in the first and third books of the Epidemics, and 

Galen described it under the name of hemitritceus. During the 

136 



ETIOLOGY. 137 

17th century it prevailed in Europe and was described as the 
febris semitertiana. Strother, Huxhara, Manningham, De-Haen 
and Stoll outlined it in the eighteenth century. Petit and Series 
o£ France, about the beginning of the present century, first dem- 
onstrated that the intestinal lesions were limited to the lower 
part of the ileum. Bretonneau, in 1826, proved that the agmi- 
nate and solitary glands of the ileum were always implicated in 
the pathological processes. He named the disease dothienenterie. 
Eouis in his elaborate work, published in 1829, named it fievre 
typlioide. Drs. Gerhard and Pennock of Philadelphia, in 1837, 
clearly outlined the difference between typhoid fever and typhus 
fever. From this time the doctrine of the identity of these two 
fevers gradually lost foot-hold, and finally was completely over- 
thrown by the series of papers published in the Medical Times 
(1849-52), by Sir William Jenner. At the present day the doc- 
trine of their non-identity is generally entertained in all parts of 
the world. 

Geographical Distribution. — Of all the fevers, this is the 
one most universally prevalent. It has been observed in all 
countries and in every clime, but prevails to the greatest extent 
in the temperate zone. It is endemic in the British Isles and in 
all parts of Europe. On this continent it is endemic from Hud- 
son's Bay to the Gulf of Mexico, and from the Atlantic coast to 
the Bocky Mountains. It has been met with in India, Egypt, 
and Australia, and has been reported as extremely common in 
Brazil and Peru. 

Etiology. — The causes of this fever may, for convenience of 
study % be arranged under the two familiar heads, predisposing 
and exciting. 

1. The predisposing causes. — Climate, indirectly, exerts con- 
siderable influence in the development of typhoid fever. For 
while the disease is met with in all countries it is especially prev- 
alent in the northern temperate zone. It frequently prevails in 
the same locality, year after year, when the surrounding condi- 
tions are favorable. As regards the season of the year, it shows 
a decided predilection for the autumn; hence the name, Autum- 
nal fever. It increases from July to ^November, and then gradu- 
ally declines, and becomes less frequent from February to April. 
The intensity of the disease is generally greater the later it be- 



138 LECTUKES ON FEVEliS. 

gins. It is always more prevalent in the country after hot and 
dry summers, than after cold and wet ones. Buchanan and 
Liebermeister have shown that the prevalence of typhoid fever 
is somewhat dependent upon changes in the height of the deeper 
springs of water, and that in localities where the disease is en- 
demic, and the specific cause is in the earth or percolates from 
privy-vaults into the earth, the lower the water-level, the more 
abundant is the fever poison. 

A decided predisposing cause pertains to age. It is pre-emi- 
nently a disease of early adult life, and occurs most frequently 
between the ages of 15 and 30. It is rarely met with at either 
extreme of life. It attacks by preference the strong and the 
healthy, and lurks alike in the palaces of the rich and the hovels 
of the poor. 

Frequently individual idiosyncrasies exist, which seem to pre- 
dispose to its attacks. Some contract the disease on the slightest 
exposure to the influence of the morbific agent, while others 
escape even after frequent and prolonged exposures. In all, 
the great predisposing cause is the special susceptibility of 
Peyer's patches to the influence of the germ. 

Habitual exposure to the poison in those not otherwise predis- 
posed, confers a certain immunity from the disease. So does 
a previous attack of the fever, for, apart from relapses, it 
seldom occurs a second time in the same individual. And clini- 
cal experience further demonstrates, that pregnant, parturient 
and nursing women, are rarely affected. 

2. The exciting causes. — The exciting causes of typhoid fever 
cannot as yet be definitely outlined. We presume it to be an 
organized germ, and to-day know its nature only by its effects. 
Professor Klebs, of Prague, believes that he has discovered the 
specific poison, and describes it as a rod-shaped bacterium about 
.004 inch long. He affirms that numbers of these micro-organ- 
isms have been constantly observed in those organs w^hich are 
most affected by the disease, and that they have been found only 
in connection with typhoid fever. Letzerich announces that he 
has transmitted typhoid fever from man to rabbits by introduc- 
ing, per os as well as hypodermatically, inferior organisms sus- 
pended in distilled water, and obtained by repeated washings of 
the dejections of typhoid fever patients. Other experimenters, 
to a limited extent, corroborate these statements, and further re- 



ETIOLOGY. 139 

searches may, at a not far distant clay, succeed in establishing 
the causal relation between these microbes and typhoid fever. 
For the present, however, the morbific agent is to us an unknown 
quantity, and we must content ourselves with simply understand- 
ing its properties. 

As we analyze the peculiarities of the typhoid poison, and 
the course of the disease, the following facts are demonstrable: 

1. Typhoid fever never occurs spontaneously, but is always 
due to a disease germ, originating from some previous case of 
typhoid fever. 

This view was first promulgated by von Gietl, of Munich, and 
was afterwards ably advocated by Dr. Budd, of England. And 
it is now generally recognized that when the disease appears in 
a locality, its development is preceded by the introduction of the 
specific typhoid poison, which has been reproduced in connec- 
tion with decomposing organic matter — in most cases human ex- 
crement. 

Neither sewer gas nor the effluvia from privy vaults are capa- 
ble of generating the disease. Filth does not create it, nor can 
the decomposition of organic and excrementitious substances 
alone produce it. It is necessary that the specific typhoid poi- 
son be incorporated in the decomposing masses, and when this is 
done the latter may become a germ center. Soil pipes and sew- 
erage may be defective for a long time, animal and vegetable 
decomposition may be constantly taking place, and yet no case 
of typhoid fever occur, until some individual having the disease 
comes within the district, or some substance containing the- 
typhoid poison is brought within the boundaries favorable to its 
multiplication and growth. 

The apparently autocthonous or spontaneous cases of the 
fever may be easily accounted for by remembering that mild or 
walking cases of typhoid, not recognized as such, or a case of 
simple intestinal catarrh due to the influence of the typhoid 
morbific agent, may import the disease germs into a hitherto 
non-infected locality. And again it is possible for the germ to 
be transported from an infected to a non-infected locality in the 
bed-linen, clothing, or other articles soiled by the dejections of 
patients, which may thus act asfomites, For already it is a dem- 
onstrated fact that the changes which take place in the stools 
of typhoid fever, and cause the reproduction and perfecting of 



140 LECTURES ON FEVERS. 

germs, may take place in the excrement discharged into the bed- 
linen or on the clothes of the sick, as well as in drains and sew- 
ers and privy vanlts. 

In whichever way it is introduced into a locality hitherto free 
from it, the affection spreads not by direct contagion, but on ac- 
count of cess-pool, privy or sewerage contamination from the 
dejections of some typhoid patient. Therefore as typhoid fever 
is never contagious from person to person, and never originates 
spontaneously but by continuous transmission of the poison, it 
justly belongs among the miasmatic-contagious fevers, in the 
sense in which they were defined in our introductory lecture. 

2. Like the germs of other acute infectious diseases the germ 
of typhoid fever is, after introduction into the human organism, 
and under favorable circumstances, capable of indefinitely re- 
producing itself. 

The time taken to so reproduce is known as the period of in- 
cubation. Its length is somewhat variable. It is longer when 
the specific poison finds access to the system by the ingesta, 
than when it reaches it through the inspired air. Being often 
an unascertainable time, the period of invasion, if not marked 
by rigors, is reckoned from the day on which the patient betakes 
himself to the bed. The prodromal symptoms are usually more 
severe in children than in older individuals. The duration of 
this stage varies according to the constitutional peculiarities of 
the patient. It ranges from fourteen to twenty-one days. 

Frequently the germ finds access to a system which is to it 
but barren soil. The surroundings are not such as to enable 
it to undergo the changes and indefinite reproduction necessary 
to give rise to typhoid fever. Acclimatization, a previous attack, 
and old age, may be mentioned as favorable conditions for the 
non-reproduction of the germ. 

3. The typhoid specific poison passes out of the organism with 
the faecal discharges, but is not capable of producing typhoid 
fever immediately, but must first undergo certain changes out- 
side the body, in connection with decaying organic matter. 

The germ of typhoid is contained solely in the alvine dejec- 
tions of the sick. And yet the fresh stools cannot communicate 
the disease, as the specific poison must go through a stage of de- 
velopment outside of the body. Hence attendants upon the 
sick do not contract the disease unless they are exposed to the 



ETIOLOGY. 141 

influence of the decomposing excrements. The patient's gar- 
ments and bed-linen only communicate the disease when they 
have been soiled with the dejections which have been allowed to 
remain exposed long enough to undergo decomposition. The 
time of innocuousness of the stools after leaving the body is very 
short, seldom longer than twelve hours. 

When associated with decomposing animal and especially 
faecal matters, the germ is capable of reproducing itself. It may 
be diffused primarily from individual privy vaults, cesspools, or 
dung-heaps; and secondarily through soakage, from individual 
contaminated springs. In large bodies of open water and in 
running streams it is rendered speedily inert. 

4. Under favorable circumstances, and in a soil fitted for its 
reception and growth, it may retain its activity for a . considera- 
ble length of time after it has passed out of the organism, and 
is also, in this situation, capable of propagating itself continu- 
ously. 

The typhoid germ possesses great vitality, and may retain it 
for a long time, during the stage of development through which 
it passes outside the body. And as Wilson says: It may be- 
found everywhere, and is readily capable of transportation from 
place to place, but it lurks in dark neglected corners and about 
the foul ways of men's dwelling-places, and creeps along with 
oozing filth, crawling into wells and springs, and hiding itself in 
the ground, choosing now a victim, and again a group of them 
but never giving rise to pandemics, or in the wider sense, even. 
epidemics, as do the poisons of typhus, cholera, or relapsing 
fever. 

In cities the complex system of continuous drainage, intensi- 
fied by that abomination, the ordinary pan water-closet, is occa- 
sionally conducive to local epidemics. But a case of fever can- 
not even here possibly infect the attendants if the alvine dejec- 
tions are promptly disinfected, and swept away into properly 
constructed, well-trapped and well-ventilated sewers. It is only 
where the excrement is improperly disinfected, or thrown into 
improperly constructed sewers, that it becomes a focus of infec- 
tion. In the country the close proximity of privy vaults, foul 
drains, or grave-yards, to drinking wells, is a common promotive 
cause. 

Local epidemics are most frequently observed in small towns. 



142 LECTURES ON EEVEES. 

and villages, while sporadic cases are constantly encountered in 
large cities and in crowded neighborhoods. 

5. It may find access to the human body either through 
drinking water or by the inspired air. 

The danger of infection is greater from drinking contaminated 
water than from any other source. But observation proves that 
the poison in contaminated water can be destroyed by boiling 
the water. Prof. I. Buckman asserts the presence of a peculiar 
*' fungoid or confervoid" growth in water contaminated by sew- 
erage or otherwise, and productive of typhoid fever. 

The experience of late years has shown that milk and meat 
are each occasionally productive of outbreaks of this disease. 
This may be explained in either of two ways: 

a. The beeves and milch cows have typhoid fever, or 

b. The water in which the milk-cans are washed, or with which 
the milk is dishonestly diluted, contains typhoid germs. 

The germs may also be propagated by the atmosphere, and in- 
fection can be produced by the inhalation of the exhalations 
from privies or sewers in which the typhoid poison exists. And 
whatever its channels of access to the organism it manifests a 
constant predilection for the lymph follicles of the ileum. 

From this brief consideration of the etiology of typhoid 
fever we are led to the following conclusions: 

1. That it is unquestionably a germ disease, although the nat- 
ure of the morbific agent is yet unknown. 

2. That it is a disease of early adult life; occurs independently 
•of over-crowding; and attacks the rich as well as the poor. 

3. That it is non-contagious ; and can be communicated only 
through the excrements, which have undergone decomposition 
after their discharge. 

4. That it is an endemic disease, and, unlike typho-malarial 
fever, prevails to a greater extent in the country than in cities. 

Clinical History. — The course of this fever may be divided 
into the following six artificial periods, each one of which may 
be modified by complications or by treatment: the prodromic 
period, the first, second, third and fourth weeks, and the period 
of convalescence. 

1. The Prodromic Period. — The disease may, in rare instances, 
seu in abruptly with a chill followed by high fever, or be pre- 



CLINICAL HISTORY. 143 

ceded by an attack resembling intermittent fever, but usually it 
is insidious in its approach. In most instances for several days 
preceding the onset of the fever, the patient feels weary, dull 
and indisposed to exertion. He complains of frontal headache, 
epistaxis, pains in the limbs, and " a tired feeling all over." His 
sleep is broken and unrefreshing. At the same time the appe- 
tite is diminished, and the tongue is swollen, and often heavily 
coated. Sometimes there are abdominal pains and diarrhea. 
After these symptoms have continued with increasing severity 
for five or six days, the fever appears, preceded either by a chill 
or chilly sensations alternating with flashes of heat, and the pa- 
tient is compelled to take to his bed. 

2. The First Week. — The onset of the disease dates from the 
first rise in temperature. In the first week, the fever steadily 
increases, and the temperature rise is gradual and uniform, with 
regular morning and evening variations (Fig. 10). The daily 
rise begins about midday and attains its maximum between 
eight o'clock in the morning and midnight. At this time the 
skin is usually hot and dry; occasionally in the morning it is 
moist, or even bathed in sweat. Sometimes chilly sensations are 
experienced as the fever increases during the latter part of the 
day. The headache now becomes violent, and the sleep is rest- 
less and disturbed. Between sleeping and waking there may be 
slight delirium. The patient feels tired, and complains of a feel- 
ing of general lameness. There are thirst and loss of appetite. 
The tongue is at first moist, swollen, and covered with a whitish- 
yellow fur; after a time it becomes drier, smooth, and red along 
the margins and tip, and is no longer swollen. In the majority 
of cases the bowels are at first constipated, but diarrhea appears 
sometime during this period. The stools are painless, brown, 
and either thick or watery. Occasionally diarrhea continues 
from the prodromic period, while not infrequently it is absent 
in the first week. Towards the close of the period, the abdomen 
becomes swollen, and is tender to pressure over the ileo-crecal 
region. The spleen is enlarged. The urine becomes scanty, 
dark-colored, and at times shows faint traces of albumen; the 
urea is increased and the chlorides diminished in quantity. Fre- 
quently mucous rales may be detected in the posterior portions 
of the lungs. A circumscribed pink flush, which deepens to- 
wards evening, and resembles the flush of hectic, appears on one 



144 LECTURES ON FEVERS. 

or both cheeks. The highest evening temperature is usually 
reached at the close of this period. 

3. The Second Week. — During the second week, the variations 
in temperature are but slight, and the fever remains at about 
the height reached at the end of the first week (Fig. 10). The 
skin is hot and dry, the face flushed and at times livid. About 
the tenth day the headache disappears, the patient becomes in- 
different, apathetic and drowsy, but has no sound sleep. Hard- 
ness of 'hearing, caused by a catarrh of the Eustachian tubes, or 
as a result of the mental state, now appears. When the patient 
is interrogated as to his condition, he usually answers that he 
feels well. All muscular movements are feeble, tremulous and 
uncertain. The tongue is dry, red, fissured and covered with 
sordes. It is protruded with difficulty, and when protruded the 
patient fails to withdraw it, unless directed to do so. The pa- 
tient lies on the back with the eyes half closed. Frequently 
there is subsultus tendinum and carphologia. He mutters in- 
coherently, and at night there is wandering delirium. Not un- 
frequently the delirium is active, and patients may become 
maniacal to such an extent as to require physical restraint. 
The mind is often occupied with whatever matters engaged its 
attention just prior to the illness. The urine and faeces are 
often passed involuntarily; at times the former is retained, and 
contains a small amount of albumen. In most cases the abdo- 
men gradually becomes tympanitic, and there is tenderness and 
gurgling, especially in the ileo-csecal region. The diarrhea in- 
creases, and the stools are of a yellowish-green color, resembling 
at times pea-soup; hence the term " pea-soup discharges." The 
spleen steadily increases in size, but owing to the tympanites, 
its borders can rarely be defined. An eruption, which is char- 
acteristic of the disease, appears between the sixth and twelfth 
days, and remains visible from eight to fourteen days. It con- 
sists of small, isolated, lenticular, light red spots, which disap- 
pear on pressure, and come out in successive crops. The spots 
vary in size from a point to a line and a half; and each individ- 
ual spot remains visible for three days, and then disappears. 
They vary in numbers from a few to many and are usually most 
abundant upon the chest and abdomen. Two or three well-de- 
fined spots are sufficient to establish the existence of the fever. 
The eruption is generally most marked in cases which occur be- 



CLINICAL HISTOEY. 145 

tween the ages of ten and thirty. Sibilant and sub-crepitant 
rales are, upon physical exploration of the chest, found to sup- 
plement the mucous rales of the first week. These rales are in- 
dicative of an extension of the catarrhal processes to the smaller 
bronchi. 

4. The Third Week. — In the third week, the morning remis- 
sions become more marked, and the fever changes from the con- 
tinuous to the remittent form (Fig. 10). This change is usually 
a gradual one, but not infrequently it takes place suddenly, some- 
times as early as the fourteenth day, with a high evening exacer- 
bation followed by a decided morning remission. The severe 
symptoms of the second week, however, continue, and frequently 
increase in intensity. For it is not until the end of this period 
that the morning remissions begin to affect the general condition 
of the patient. And it often happens that the symptoms which 
belong to the latter half of the second and the beginning of the 
third week, and which collectively constitute the typhoid state, 
are not fully developed until after the middle of this period. 
The strength steadily weakens, and the patient is, now, no longer 
able to raise himself, or even turn in bed. The stupor deepens, 
and the faeces and urine are passed involuntarily, or the latter 
may be retained. Emaciation becomes more and more marked, 
and bed-sores are apt to form at points of pressure. Sudamina 
frequently appear on the neck, chest, and abdomen. The pulse 
grows frequent and feeble. It is during this period that most 
of the complications, especially those of the respiratory organs, 
are developed. 

5. The Fourth Week. — The fever is now decidedly remittent, 
and as the defervescence draws to a close, becomes distinctly in- 
termittent (Fig. 10). The morning fall in temperature is each 
day lower, and the evening exacerbation is less decided. There 
is a gradual amelioration of all the symptoms. The stupor dis- 
appears and the patient returns to consciousness. The tongue 
begins to clean, the thirst lessens, and the appetite returns. The 
tympanites diminishes, and the stools are less frequent, darker, 
and of greater consistence. The urine is increased in quantity 
and lighter in color. The skin is ofttimes bathed in sweat, es- 
pecially during sleep. The pulse becomes less frequent, and 
fuller. And the spleen returns to its natural size. Notwith- 
standing an amelioration in all the other symptoms occurs dur- 



146 LECTURES ON FEVEES. 

ing this period, the emaciation progresses with marked uni- 
formity, until tj|g temperature range reaches the normal. And 
frequently, so great is the emaciation, that during the course of 
the disease the patient loses one-sixth or one-seventh of his body- 
weight. 

6. Convalescence. — The disappearance of the fever marks the 
period of convalescence. Frequently in the early days of this 
period the morning temperature becomes sub-normal. From 
this time, the weight of the body rapidly increases, the appe- 
tite returns, and the patient gains strength daily. Eelapses 
(Fig. 11) occur in about three per cent of the cases, while "re- 
crudescences of the fever" or attacks of "after fever" are eas- 
ily brought about by such errors in diet as overfeeding or the 
too early indulgence in solid food, or by over-exertion mentally 
or physically. Danger of perforation of the intestine from deep 
ulceration of the glands of Peyer, exists always after the first 
week until late in convalescence. And it is not an infrequent 
occurrence for patients out of bed for a week or two, to die 
suddenly from this cause. Usually convalescence is tedious, and 
months frequently elapse before the average typhoid-fever pa- 
tient regains his accustomed health. 



LECTURE XL 

Typhoid Fever (Continued). 

In my last lecture I described to you the prominent symptoms 
of a typical case of typhoid fever. To-day, before proceeding 
to an analytical study of the principal symptoms of the disease, 
I would invite your attention to two types of cases which run 
an irregular course ; I refer to the mild and the abortive forma. 

1. Mild Typhoid Fever. — In mild or "walking cases" of 
typhoid fever, the onset is gradual, the symptoms are only mod- 
erately severe, and the fever runs its regular course, but is of low 
grade. In the majority of these cases the periods approach in 
orderly succession, but are shortened, so that the disease runs 
its course in from sixteen to twenty days. Upon the fourth or 
fifth day the temperature may reach 104° Fahr. Occasionally 
the temperature curve follows that of a typical case, and differs 
from it only by running one degree lower. Usually the erup- 
tion appears early, the spots are few, and there is only one crop. 
The diarrhea is mild in character; at times it is absent; and oc- 
casionally it alternates with constipation. Some cases of this 
type — the so-called " walking cases " — are so mild that the j)a- 
tients are not at any time confined to the bed. All cases of ty- 
phoid fever, however, be it remembered should take to the bed 
unreservedly and remain there until convalescence is fully es- 
tablished. For no matter how mild the attack, the intestinal 
changes may be such, that slight physical exertion shall in an 
unfortunate moment cause intestinal perforation, the almost 
inevitable termination of which is death from peritonitis. 

2. Abortive Typhoid Fever. — This form is rare in this country 

147 



148 LECTUEES ON EEVEES. 

though not uncommon in Europe. It may be ushered in, either 
suddenly without prodromes, or gradually with all the symptoms 
of a typical case. The temperature curve follows the regular 
course during the first week, and by the evening of the third or 
fourth day may reach 104° or 105° Fahr. But after the middle 
of the second week, the fever may disappear abruptly, with pro- 
fuse sweating, and the temperature may fall rapidly to the nor- 
mal standard. The eruption, the diarrhea, the delirium, and all 
the urgent symptoms of the disease may be present, and yet be- 
fore the termination of the second period, the patient may have 
fully convalesced. Positive evidence of the typhoid origin of 
these cases exists in the fact that on post-mortem examination, 
the characteristic typhoid lesions are found. As "Wilson says, 
these irregular forms are analogous to modified small-pox, in 
which we have the primary fever well marked, but in consequence 
of the slight' local lesions of the skin, and the absence of suppu- 
ration, there is no secondary fever. It is probable that they are 
to be explained upon the same ground, namely, that while the 
constitutional disturbance due to the primary action of the ty- 
phoid poison is very great, the intestinal lesion, for some un- 
known reason — doubtless dependent upon the constitutional pe- 
culiarities of the patient — is moderate, and the glandular deposit 
undergoes resolution without ulceration or sloughing. Dr. Cay- 
ley suggests that the cases of typhoid fever that are from time to- 
time described as having been cut short by special remedies or 
plans of treatment, are really of this character, the observer hav- 
ing ascribed to the remedy changes which are, in fact, natural 
phenomena of particular cases of the disease. 

ANALYSIS OF CHAET. 

The Digestive Tract. — At the outset of the disease the tongue- 
is moist, and covered with a thin, whitish or yellowish-white 
coat. Towards the end of the first week it may become red at 
the tip and edges, and display a tendency to become dry in the 
center. It may remain moist and coated during the whole course 
of the fever, or as the disease passes into the second week it may 
become brown, dry and fissured. At any period the coating may 
become flaky, suddenly peel off, and leave the tongue of a shiny, 
beefy red appearance. Usually towards the third week the 
tongue is protruded tremblingly, and is dry, red and glazed, and 
shows a brownish streak along the center, or a triangular brown- 



CHART. 

CHAKT YIIL— Typhoid Fever. 



149 



1 Character: 


Non-Contagious. A previous attack affords partial protection. 


\ Incubation: 


Three weeks. Prodromal stage, 5 to 10 days . 


Period. 


First week. 


Second week. 


Third week. 


Fourth week 


Tongue ; 


White coating, 
Red edges and tip. 


Dry, red, glazed. 


Dry. Sordes. 
Brownish crusts. 


Moist 
in recovery. 


Intestinal 
Canal: 


Nausea. Green- 
ish vomiting. 
Thin, brown dia- 
rrhea. 


"Pea-soup" X. Hemorrhage \lndigestion 
discharges . X^ \. 

Perforation. \ 


Temperature ; 


Rises 2° and falls 
1° every day . 
Maximum on 

evening- of fifth 
day. 


103° to 104°. 


Oscillation. 

Falls 4° 

between night and 

morning. 


Returns to 
the normal. 


Pulse: 


100 per minute. 


100 to 110. 


120 to 140. 
Dicrotic. 


Approaches 
the normal. 


Skin: 


Hot. Hyperajsthetic. 
'•Musty odor." 


Bed-sores. 


Furuncles. 


Eruption : 


Rose-rash on 

seventh day. 


Remains from 8 to 14 days. 
Each spot lasts 3 da vs. 


Sudamina. 


Nervous Sys- 
tem: 


Headache, wake- 
fulness. 


Somnolence. 
Asthenic delirium 


Deliiium. Tremu- 

lousness. 
Subsultus tendin- 
iim, Deafness. 


Prostration. 


Head: 


Epistaxis- 


Face pale or livid. 
Cheeks flushed. 


Falling off 
of the hair. 


Urine : 


Diminished. Dark. 
Sp. gr. 1020 to 1030 


Increased. 
Light. 


Copious. Pale. 

Spr. gr, 

1008 to 1005. 


Abdomen : 




Tympanites. Gurgling. 
Right ileo-caecal region tender after the 6th day. 


Complicati'ns : 


Bronchial catarrh. 


Bronchial catarrh. Lobular pneumonia. 
Intestinal perforation. Parotitis. 


Peyer's Patch- 
es; 


Catarrhal inflam- 
mation. 
Medullary infil- 
tration 


Follicles swollen 

Softening and 

Necrosis. 


Ulceration 


Cicatrization. 


Spleen: 


Enlarged. 


Diminished. 


Sequels: 


Debility. Paralysis. Abscesses. 


Prognosis: 


Mortality, 1 in 5. Typhoid fever occurs between ages of 18 and 35. 



250 LECTUEES ON FEVEES. 

ish patch at the tip. In severe cases the entire month and tongue 
may be covered with brownish incrustations. As convalescence 
approaches, the tongue becomes moist, first about the edges and 
then along the dorsum, and gradually returns to its natural con- 
dition. The lips often crack, and become covered with sordes, 
which when removed cause them to bleed. In rare instances 
hemorrhage from the gums occurs. Slight catarrhal inflamma- 
tion of the fauces and pharynx, with its attendant annoying se- 
cretion is usually present during the first week. Later the secre- 
tion ceases, and owing to changes in the salivary glands, the 
mouth and throat become dry, and swallowing is difficult. In 
children difficult deglutition is occasionally due to pharyngeal 
hyperesthesia, the fluids being rejected through the nostrils. 
Parotitis may appear in severe cases during the third or fourth 
week, and is of unfavorable omen. The enlargement commonly 
suppurates and is then very often fatal. Thirst is generally 
present, and in a large proportion of cases is excessive. 

The appetite is impaired from the start, and as the tongue be- 
comes dry is wholly lost. Nausea and vomiting are not uncom- 
mon during the first week. Usually, however, they appear dur- 
ing the second week, and in severe cases may be associated with 
more or less epigastric tenderness. The matters vomited usu- 
ally consist of a greenish fluid. When vomiting comes on after 
the end of the second week, either it is due to gastric catarrh or 
appears as the first sign of peritonitis, 

Diarrhea is one of the most common attendants of typhoid 
fever. It may be present during the prodromic period, or not 
appear until the third or fourth week. The second week is the 
usual time for its appearance. The average number of evacua- 
tions is three or four in twenty-four hours. At times from 
twelve to fifteen movements may take place per day. A mild 
diarrhea is a favorable rather than an unfavorable symptom. 
Generally the urgency of the diarrhea bears no constant relation 
to the extent of the intestinal lesions. During the first week the 
stools are thin and brownish, and have an alkaline reaction. 
Later they are of a yellowish-green color, assume the peculiar 
typhoid appearance, and contain micrococci and other bacterial 
forms. From this time they are known as "pea-soup dis- 
charges." 



ANALYSIS OF CHAET. 151 

Gurgling and tenderness in the right iliac fossa, are often 
elicited on palpation. Spontaneous pain is frequently com- 
plained of. The abdominal pain and tenderness, which are gen- 
erally present after the sixth day, are due to local morbid pro- 
cesses, and hence increase as the disease progresses. While ex- 
amining the abdomen at this time to ascertain the amount of 
tenderness, all pressure should be made with the palm of the 
hand, never with the ends of the fingers. Usually the expression 
of the countenance will enable you to determine whether you are 
or are not by the pressure, causing pain, long before the patient 
makes an audible complaint. 

Intestinal hemorrhage occurs in about five per cent of the cases, 
and varies in quantity from a mere trace of blood to one or more 
quarts. If the blood is promptly discharged, it is of a bright 
red color, owing to the alkaline condition of the intestinal con- 
tents, and is either syrupy or loosely clotted. If it be retained 
for some time in the intestine ( concealed hemorrhage ) it assumes 
a tarry consistency, and is of an olive-green or brown color. 
The slight hemorrhages which occur prior to the latter part of 
the second week, arise from the ruptured capillaries of the mu- 
cous membrane. The more profuse hemorrhages of the third 
and following weeks are due to the separation of sloughs, or to 
the destructive action of progressive ulceration. The usual time 
for the occurrence of extensive intestinal hemorrhages is in the 
latter part of the second and during the third week. In the ma- 
jority of instances they occur in severe cases, and especially such 
as are attended by profuse diarrhea. These hemorrhages are 
usually announced by an abrupt but transitory fall in tempera- 
ture, and by the speedily ensuing symptoms of collapse. 

Perforation of the intestine occurs mostly between the third 
and fifth week, and is more frequent among men than women. 
The perf oration is in the majority of instances found in the lower 
portion of the ileum. Usually, it presents a round opening in 
the peritoneal covering, varying in size from a pin's head to a 
split pea. It extends inwards in the shape of an inverted fun- 
nel, and corresponds either to an ulcerated Peyer's patch, or, less 
frequently, to a solitary gland. The margins of the opening 
usually present a "punched-out" appearance. At the time of 
the perf oration, the patient frequently experiences a sudden pain, 
£rct in the right iliac fossa but soon extending over the entire 



152 LECTUKES ON EEVEKS. 

abdomen. Following this a state of collapse supervenes. The 
abdomen becomes rapidly tympanitic, the temperature falls, the 
pulse is quick and feeble, the countenance anxious and sunken. 
Nausea and vomiting are marked, and there is coldness and 
blueness of the extremities. Occasionally in severe cases the 
patient dies during the collapse. Usually, however, he survives 
the shock, the temperature rises, and a fatal termination does not 
occur until the third or fourth day. In rare instances recovery 
may take place. 

Tympanites is a very common symptom, existing to some ex- 
tent in all cases. It makes its appearance about the end of the 
first or the beginning of the second week, and remains until con- 
valescence is fully established. The distention steadily increases 
as the fever advances, and attains its maximum in the latter half 
of the third or in the fourth week. It is due partly to the ex- 
cessive development of gas, and partly to deficient expulsive 
power. After its appearance a gurgling sound maybe produced 
by pressing firmly over the right iliac fossa. Tympanites is in 
part a measure of the extent of the intestinal mischief, and is al- 
ways an important diagnostic sign. And, generally, it may be 
stated, that in typhoid fever, no matter how favorable the other 
symptoms appear, so long as the abdomen remains tympanitic, 
the patient is in more or less danger. 

The Spleen. — Enlargement of the spleen, with tenderness, is 
a very prominent symptom. It appears early in the disease, in- 
creases uniformly during the second week, and then, gradually 
diminishes. It is greatest in individuals under thirty years of 
age, and at the height of the disease may be three times the 
natural size of the organ. 

The Temperature. — In well-marked uncomplicated cases of 
this disease, the course of the fever may be divided into four 
periods, each of which is characterized by a special thermometric 
curve. The average duration of each of these periods is seven 
days. Occasionally the typical course of the fever is disturbed, 
and in consequence the duration of the periods may be shortened 
to five days or lengthened to eight or nine clays. 

The typical thermometric variations of a severe case of typhoid 
fever are well outlined in Fig. 10, and those of a mild case are 
represented in Fig. 11. From the first day of the development 



TEMPERATURE CYCLE. 



153 




154 LECTURES ON FEVERS. 

of the fever, and through the first period, the pyrogenic course 
of the disease is rapid and progressive. The temperature for 
three or four days rises about 1.8° Fahr. to 2.7° Fahr. from each 
morning till evening, and falls again from the evening to the 
following morning 0.9° Fahr. to 1.3° Fahr. Between noon and 
evening of the fourth or fifth day, the maximal height, 104° to 
106°, is reached. The daily rise begins about noon, and is com- 
pleted before 11 P.M., usually between 4 and 7 P. M. The fall 
occurs between midnight and 10 A. M., oftener between 6 and 9 
A. M. Tavo temperature observations should be taken daily; one 
about 8 A. M., and the other about 9 P. M. 

In the second half of the first week, and the first half of the 
second week, the course of the temperature is quite uniform, and 
the fever »ls described as continuous. Towards the close of the 
week, the evening rise often falls a little, and the morning re- 
missions become a trifle more marked. All irregularities in the 
second week, should be viewed with suspicion. A severe course 
of the disease may be predicted, when the morning temperatures 
remain stationary at 103° Fahr., and the evening ones above 
104.9° Fahr., and when the temperature does not moderate be- 
fore the twelfth day. Kecovery rarely takes place after a morn- 
ing temperature exceeding 104.9° Fahr., or an evening tempera- 
ture exceeding 107.2° Fahr. If the morning temperature exceeds 
105.8° Fahr. death is almost certain. 

In the third week, the morning remission becomes marked, 
and with it the temperature falls, although the evening exacerba- 
tions may reach the same degree as in the week preceding. The 
change of the fever from the continuous to the remittent form is 
usually gradual, occasionally it is sudden, and is then announced 
by a high evening temperature followed by a decided morning 
remission. By the end of the third week the morning tempera- 
ture during the remission, will be two or three degrees lower 
than during the second week. The surest course towards con- 
valescence is mapped out by increased morning remissions suc- 
ceeded by milder evening exacerbations. 

In the fourth week, the fever changes from the remittent to 
the intermittent type. The morning temperature is each day 
lower, and the evening exacerbation less decided (Fig. 11), so 
that frequently by the end of the week the normal standard is 
reached. In severe cases a striking rise of 0.9° Fahr., or more, 



TEMPER A.TUKE CYCLE . 



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156 LECTURES ON EEVEES. 

about the twenty-fifth day, happening in the middle of a well- 
marked remission is a not uncommon occurrence. 

Convalescence may be said to be established when the ther- 
mometer shows absence of fever for two successive evenings. 
Frequently during this period the temperature falls to 96.8° 
Fahr. or 97.73 Fahr. in the morning, and under 98.6° Fahr. in 
the evening. Belapses are to be dreaded if elevations of tem- 
perature above the normal occur eight days after the beginning 
of convalescence (Fig. 12). 

The Pulse is increased in frequency in proportion to the rise 
in temperature. During the first week it becomes more and 
more frequent, and at its close may reach 100 or 110 per minute. 
Throughout the second week it remains at about the same height. 
In the third and fourth weeks it may either gradually diminish 
in frequency or run as high as 120 or 140. Accidental causes, 
such as simply lifting the patient in bed, may increase the pulse 
twenty or thirty beats per minute. A pulse which, without 
special cause, remains for five or six consecutive days above 120 
per minute, is a bad omen, and usually indicates the commence- 
ment of a paralysis of the heart. 

In the early stages the pulse is full and frequent; later it be- 
comes soft, compressible and dicrotic, and in the advanced stages 
it may be small, undulating, irregular or uncountable. After the 
second week, should it any time become irregular and intermit- 
ting, the heart's impulse imperceptible, and the first sound in- 
audible, a fatal issue may be anticipated. Marked coldness of 
the hands and feet, occurring while the internal temperature is 
high, is an important sign of impending danger from failure of 
the heart. Collapse which occurs in consequence of a sudden 
fall of temperature is a not unfavorable indication. 

The Eespirations rise with the pulse. Frequently there is 
bronchitis, with shallow, and rather rapid breathing, with some 
sonorous rales over the chest. The peculiar character of these 
rales, which give a dry, ringing sound, often enables you to make 
the diagnosis of typhoid fever positive. Lobar pneumonia is a 
common complication, especially in the last part of the second, 
and in the third week. 

Hypostasis and pulmonary oedema may occur any time after 
the second week, as a result of the enfeeblement of the circula- 
tion. Acute miliary tuberculosis is an occasional sequel. 



ANALYSIS OF CHART. 157 

The Cutaneous Surface. — In severe cases by the second week 
the countenance has a pale, livid, muddy apj)earance, and circum- 
scribed rose-colored spots are formed over one or both cheek- 
bones. Sometime between the seventh and the fourteenth day 
from the beginning of the fever (the patient usually taking to 
his bed on the fifth day), that characteristic symptom of typhoid 
fever — the eruption — makes its appearance. It is occasionally 
preceded by a faint scarlet rash, and is found mostly upon the 
abdomen and lower part of the chest, between the nipple and the 
umbilicus, especially on the right hypochondrium over the ar- 
ticulation of the cartilage of the eighth rib. It consists of small, 
slightly elevated, round or oval, deleble, rose-colored spots, 
which vary in diameter from a point to a line and a half. The 
spots are developed in successive crops, and each spot remains 
visible three days. They resemble flea-bites, although paler in 
color. They disappear upon slight pressure, and return imme- 
diately when the pressure is removed. They are usually few 
in number,run their course without change, and disappear leav- 
ing no trace upon the skin. They give no feeling of hardness 
to the finger passed over them, and are not seen after death. 
The duration of the eruption is three, eight, or ten days. It 
disappears before convalescence is established, but may re-ap- 
pear in true relapses. It is most marked between the ages of 
ten and thirty. Jenner found it present in 148 out of 152 cases. 

Late in the disease, minute transparent vesicles, called Suda- 
ni ina, frequently appear over the surface of the body. Boils 
and abscesses are very often met with. Bed-sores, defined as 
gangrene resulting from pressure, frequently form over the 
sacrum and trochanters, and at times over the elbows, heels and 
occiput. They prove troublesome and often serious complica- 
tions of typhoid fever. The hair falls during convalescence. 
All through the disease the skin emits a musty odor, which is 
held by some to be pathognomonic. 

Emaciation appears early and is progressive. So general is 
it that even after convalescence is established a long time often 
elapses before the patient regains his normal healthy appear- 
ance. Occasionally after a severe attack of the fever, the system 
undergoes a change, and patients who have heretofore been 
lean become fat, and vice versa. 



158 LECTURES ON FEVEES. 

The Urine is diminished in quantity during the first two 
weeks of the fever, and has a typhoid odor, like the body. It is 
then darker in color and has a specific gravity of from 1020 to 
1030. In the advanced stage of the fever, and especially during 
convalescence, it is pale, copious, foaming, and. of low specific 
gravity. The amount of urea excreted is increased about one- 
fifth, and is greatest when the temperature is highest. The 
chlorides are greatly diminished during the fever, but re-appear 
as convalescence is established. Albumen appears in urine in 
nearly one-third of the cases. When present the amount is 
small, and of short duration. It rarely appears earlier than the 
middle of the third week, but when it does appear it is apt to be 
associated with grave cerebral symptoms. Eenal epithelium and 
tube-casts are frequently discovered along with the albumen. 
Late in the disease the urine often contains a large amount of 
phosphates. Catheterism is frequently rendered necessary, after 
the second week, on account of urinary retention. Yesical ca- 
tarrh not rarely occurs during convalescence. 

The Nervous System. — Headache is one of the earliest and 
most constant symptoms of typhoid fever. It is usually de- 
scribed as a dull, heavy pain, and is commonly confined to the 
forehead and temples; sometimes it extends over the whole 
head. It is most severe during the first week, and ceases spon- 
taneously about the tenth day. Associated with it, there are 
slight vertigo, intolerance of light, and pain in the back and ex- 
tremities. 

Somnolence usually appears sometime during the second week. 
At first the drowsiness is only slight, but later, especially in 
severe cases, it becomes more and more profound. Frequently 
it is interrupted by delirium. In children somnolence is a fre- 
quent and valuable diagnostic sign. 

At any time the occurrence of hysterical manifestations should 
render the prognosis guarded as to coming nervous symptoms. 

Delirium is commonly present. It is often slight and may 
occur chiefly at night time, or between sleeping and awaking. 
It rarely appears before the middle of the second week, though 
exceptionally maniacal delirium is the first symptom leading to 
the supposition that the patient is ill. The characteristic form 
of the delirium is the " low muttering." Sometimes, however, 



ANALYSIS OF CHART. 159 

it is active and noisy from the start, so as to render physical re- 
straint necessary. The mind is dnll and stupid. 

Muscular prostration is noticeable in all severe cases from the 
beginning of the fever and increases with its progress. It is 
usually most marked during the second or third week. Reten- 
tion of urine and involuntary evacuations from the bowels, 
when occurring early in cases in which the prostration is ex- 
treme, are unfavorable symptoms. Vesical paralysis is a not 
uncommon sequel. 

Muscular tremors, especially trembling of the hands, tongue, 
and lips, are oftenest met with in old and feeble persons, and in 
those who are addicted to the use of spirits. In the advanced 
stages of severe cases, subsultus tendinum, carphologia, and hic- 
cough are observed. General convulsions are rare, except in 
very young children. Paraplegia occasionally appears either dur- 
ing the course of the fever, or after the commencement of con- 
valescence. 

The Special Senses. — Epistaxis is a common symptom and 
is apt to occur early in the disease. 

Deafness is most marked about the middle period of the fever 
and usually affects both ears. One-sided deafness is generally 
caused by ulceration of the mucous lining of the Eustachian 
tube, or by suppuration of the middle ear. In severe cases, 
ringing and humming in the ears are complained of during the 
early days of the fever. At the middle of the second week, about 
the time the delirium appears, the pupils will be found abnor- 
mally dilated. In rare instances paralysis of accommodation 
occurs as a sequel. 

Hyperesthesia of the surface of the body is common in fe- 
males and in children. It is most marked over the abdomen and 
lower extremities, and is generally associated with tenderness 
along the spine. 

Duration. — The average duration of typhoid fever is from 
three to four weeks. In a typical case the length of the stage 
of invasion varies from one to five days. The stage of glandular 
enlargement continues until the twelfth or fourteenth day, and 
the ulcerative stage extends from the fourteenth day to some- 
time between the twenty-first and twenty-eighth days. The 



160 LECTUEES ON FEVEES. 

stage of convalescence lias an average length of from one to two* 
weeks. The period of greatest danger is about the close of the 
third week. Death seldom occurs earlier than the fourteenth 
day. 

Relapses. — A relapse has been defined as a second evolution 
of the specific febrile process after the establishment of convales- 
cence, and is due to re-infection by the specific cause, either from 
a new and second infection from the source of the original poison, 
or, which appears more probable, from resorption of the poison 
thrown off in the faeces. It is usually milder and of shorter du- 
ration than a primary attack. Most commonly it occurs singly 
though occasionally a second or even a third may take place. 
It may be ushered in by chilliness or rigors, or declare itself, 
after a period of interval of from one to five days, by a sudden 
recurrence of febrile symptoms. The temperature bounds at 
once to 103° Fahr. or 104° Fahr. and may be either continuous 
or attended by remissions (Fig. 12). The eruption reappears, 
frequently as early as the fourth day, the spleen again enlarges, 
the intestinal and abdominal symptoms return, and the majority 
of the characteristic symptoms of the primary attack are repro- 
duced. The fever attains its maximum about the evening of the 
fifth day, and a critical fall takes place about the eighth or ninth 
day. On the tenth day a decided rise again occurs. From this 
time the morning remissions become more and more pronounced 
and the temperature returns in a zigzag manner to the normal 
degree with convalescence. A fatal termination is a rare occur- 
rence unless perforation takes place. The intestinal lesions of 
a relapse are usually less numerous than in a primary attack, and 
the ulceration is higher up. 

" After fevers" or "recrudescences of fever" which are gen- 
erally dependent upon unhealed ulcers, and arise from dietetic 
errors or over-exertion, are entirely different from true relapses, 
and last only a few days. 

Morbid Anatomy. — The anatomical lesions of typhoid fever 
are in many instances so peculiar and characteristic that at an 
autopsy, an experienced observer can, without previous knowl- 
edge of the history and symptoms of the case examined, make a 
positive diagnosis. 

Early in the disease, as soon as the characteristic symptoms 



RELAPSE. 



161 



x 

> 




- 



162 LECTURES ON FEVERS. 

appear, the blood becomes darker in color and gradually loses its 
fibrin. Later it becomes thin and watery, and the number of 
white globules is largely increased. The spleen becomes en- 
larged, softened and pigmented. The enlargement begins 
early, and attains its acme at the beginning of the third week. 
It then gradually diminishes, and reaches the normal during 
convalescence. On section the organ is found to be of a brown- 
ish-red, almost black color. In the early stages it is of moderate 
consistence, but later it is a soft, friable, jelly-like mass. Near 
the close of the disease infarctions are often met with, and in 
rare instances, spontaneous rupture occurs. According to Ger- 
hardt, in cases in which relapse takes place, the spleen frequently 
remains enlarged during the apyrexial period between the pri- 
mary attack and the relapse. The liver is in most cases normal 
in appearance; occasionally it is softened, and the cells are more 
or less granular and fatty. Nodules, consisting of lymphoid 
cells are at times found along the course of the small veins. 
The amount of bile is generally diminished, and in the later 
stages it is thin and almost colorless. 

The Kidneys. — Degenerative changes in the kidneys are usu- 
ally associated with albuminuria, When present they affect 
first the cortical and later the medullary portion of the organ. 
Infarctions are sometimes observed. 

The heart undergoes parenchymatous degeneration in propor- 
tion to the intensity and duration of the febrile movement. In 
most instances it becomes soft, flabby, friable, and of a pale gray 
or "faded-leaf" color. On microscopical examination, the mus- 
cular fibres will be found to have undergone granular degenera- 
tion, sometimes to such an extent as to efface the striations. 
The feebleness of the heart's action, especially in severe cases, 
is always proportionate to the extent of this degeneration. 

The Lungs. — The dependent portions of the lungs frequently 
present the condition of hypostasis. When the hypostasis is 
complete, the lung tissue is of a dark brown or black color, and 
is then in the condition termed splenization. The bronchial 
glands are at times enlarged, and evidences of pneumonia are 
ofttimes present. Pulmonary oedema is frequently observed. 
In the bronchial tubes — especially the larger ones — evidences of 
catarrhal inflammation are almost always found. The larynx is 



THE INTESTINAL LESIONS. 163 

"frequently the seat of catarrhal inflammation; less frequently it 
is the seat of more or less extensive ulceration. Dangerous 
hemorrhages sometimes take place from these well-designated 
" typhoid ulcers of the larynx." At times the ulceration involves 
the epiglottis, and it may extend upward and outward to the 
Eustachian tube. 

The Nervous System. — The brain and nervous system present 
.no known characteristic lesion, although not infrequently ad- 
hesions of the dura mater are found early in the disease, while 
oedema of the pia mater and brain structure occur later in its 
•course. 

The Muscles. — The voluntary muscles may be the seat of either 
granular or waxy degeneration. The granular degeneration is 
more frequent, and corresponds to ordinary fatty degeneration. 
In waxy degeneration the muscle substance is converted into a 
waxy, shining mass. Muscular degeneration is most marked in 
the second, third and fourth weeks. The abdominal rectus, the 
adductors of the thigh, the pectorales, the diaphragm and the 
tongue are of tenest implicated, and always to the greatest extent. 
The want of muscular power which appears at the height of the 
disease is due in part to disturbances of the nervous system and 
in part to muscular changes ; but the excessive loss of power 
during convalescence is almost entirely due to these degenera- 
tive changes of muscular tissue. 

Cadaveric rigidity is usually marked, and long lasting. 

The Digestive Tract. — Early in the disease the salivary glands 
and pancreas become hard and undergo granular degeneration. 
At first they have the consistence of cartilage and are of a brown- 
yellow color. Later the hardness diminishes, and they present 
a reddish appearance. After the third week ulcerative changes, 
may, in rare instances, be found in the pharynx, and at the car- 
diac extremity of the oesophagus. The stomach is at times hy- 
persemic, and may be the seat of extensive degenerative glandu- 
lar changes. 

The Intestinal Lesions. — The principal lesions of the intestinal 
canal involve the agminate and solitary glands of the ileum and 
are characteristic of the disease. The course of the pathological 
changes which result in these lesions, may, for the convenience 
of study, be divided into four stages corresponding to the four 



164 LECTURES ON FEYEES. 

periods of the fever. In the first week — the stage of catarrhal 
inflammation and of medullary infiltration — the mucous mem- 
brane, especially that surrounding the Peyerian patches, becomes 
hypersemic and swollen. The agminate and solitary glands be- 
come infiltrated with lymphoid cells, and the patches are thick- 
ened, hardened and elevated from one to three lines above the 
surrounding membrane. Their surface assumes a dark reddish 
color; forming what is known as the " shaven-beard appearance.' ' 
These changes are generally well marked as early as the second 
day, but are not fully developed until the end of the first week. 

In the second week — the stage of softening and necrosis — the 
mucous membrane becomes less hypersemic, but the agminate 
and solitary glands become more elevated and infiltrated. The 
follicles become swollen in all directions, from the excessive de- 
velopment of cell elements. As a result of the pressure of these 
cells upon the capillary vessels which furnish nutrition to the 
glandular structure, the glands become anaemic and degenerative 
changes occur. In some of the glands by the middle of the 
second week the new elements undergo disintegration and ab- 
sorption, and the process ends in resolution. In others the in- 
dividual follicles rupture, and discharge their contents into the 
intestinal canal. More frequently the swollen patches undergo 
partial or complete necrosis, and yellowish-brown or greenish 
sloughs are formed. 

In the third week — the stage of ulceration — the necrotic tissue 
separates, leaving a typhoid ulcer with sharp everted and over- 
hanging edges. The size and depth of the ulcer correspond to 
the area of the necrosed tissue. They are elliptical when an 
entire patch is necrotic, and small and round when the infil- 
trated solitary glands are necrosed. Usually by the end of the 
second week the sloughs are all detached. 

In the fourth week — the stage of cicatrization — the swollen 
edges of the ulcers gradually subside, and the surface becomes 
covered with granulation tissue, which is transformed into con- 
nective tissue, and ultimately covered with a layer of epithelium. 
The gland structure is not regenerated. The resulting scar is 
slightly depressed, firm, less vascular than the surrounding mu- 
cous membrane, often more or less strongly pigmented, and can 
be recognized after the lapse of years. It never causes pucker- 
ing, and never gives rise to diminution in the calibre of the in- 



DIFFEKENTIAL DIAGNOSIS. 165 

testine. Not infrequently the process of healing does not pur- 
sue this regular course and terminate thus favorably. In some 
instances while one portion of the ulcer is undergoing cicatriza- 
tion, in another part the process of ulceration may be extending. 
Such long-continued ulceration may prolong convalescence, and 
occasionally cause death, either from exhaustion or by per- 
foration. 

The Mesenteric Glands undergo changes analogous to those 
which take place in the intestinal glands. In some cases all the 
glands are affected, but usually the changes are confined to those 
which correspond to the diseased portion of the intestine. They 
are first congested and then enlarged in consequence of cellular 
hyperplasia. The maximum of enlargement is reached about 
the middle of the second or beginning of the third week. The 
size attained varies from that of a chestnut to a small hen's egg- 
In the retrogression some of the glands simply shrink and re- 
turn to the normal state. Others undergo softening and ab- 
sorption, and leave a fibrous cicatrix. Still others of large size* 
are only incompletely absorbed, the cheesy matter which is left 
undergoing, in process of time, calcareous degeneration. And a 
few after softening, form pseudo-abscesses, which may burst 
into the peritoneal cavity and cause general peritonitis. 

A calcareous state of the mesenteric glands, and pigmented 
cicatrices of the solitary and agminate glands, are almost posi- 
tive autopsic symptoms of a previous severe case of typhoid 
fever. 

Differential Diagnosis. — The diagnosis of well-marked cases 
of typhoid fever is usually attended with but little difficulty. 
The presence of the febrile movement with nocturnal exacerba- 
tions and morning remissions, and the appearance of frontal 
headache, epistaxis, bronchial cough with sonorous rales, and 
•diarrhea, during the first week, are sufficiently suggestive of the 
disease. The progressive enlargement of the spleen, the tender- 
ness over the region of the ileo-csecal valve, and the tympanites 
are also diagnostic. Equally characteristic are the rose-colored 
spots, the pea-soup or ochre-colored dejections, and the mutter- 
ing delirium. In mild, abortive and irregular types it is always 
■difficult and ofttimes impossible to form an accurate diagnosis. 

The diseases with which typhoid fever is most liable to be con- 



166 



LECTURES ON FEVERS. 



founded are, simple continued fever, simple remittent fever r 
typho-malarial fever, typhus fever, relapsing fever, acute tuber- 
culosis,pneumonia, influenza, gastro-enteritis and trichiniasis. 

Simple continued fever as distinguished from typhoid fever is 
characterized by the abruptness of the rise and fall of tempera- 
ture, by the absence of eruption and of abdominal symptoms? 
and by its short duration. 

The rules for differentiating simple remittent fever (p. 84) 
and typho-malarial fever (p. 118), from typhoid fever, have al- 
ready been given in the lectures upon those diseases, and as 
they are familiar to you, their repetition is unnecessary. 

The leading phenomena of typhus fever, relapsing fever, and 
typhoid fever, may be contrasted, for the purpose of establishing 
their clinical distinction, according to the following tabular ar- 
rangement: 



TYPHUS FEVEE. 


TYPHOID FEVEE. 


EELAPSEKG FEVEE. 


An epidemic disease. 


An endemic disease. 


An epidemic disease. 


Highly contagious. 


Non-contagious. 


Contagious. 


Onset sudden. 


Onset insidious. 


Onset sudden. 


Course continuous. 


Course continuous. 


Course broken by a dis- 
tinct apyrexial period. 


Duration about 14 days. 

Defervescence critical or 
by rapid lysis. 


Duration 3 to 4 weeks. 

Defervescence by pro- 
longed lysis. 


Duration of primary par- 
oxysm 5 to 7 days : of 
intermission 4 to 7 
days ; and of relapse 3 
days. 

Terminates abruptly by 
crisis. 


Relapses rare. 


Relapses occasionally. 


Relapses constant. 


Countenance, dusky-red. 


Countenance, pale or pur- 
plish-red. 

Flush circumscribed and 
confined to cheeks. 


Countenance flushed. 


Conjunctivae deeply in- 
jected ; pupils con- 
tracted. 


Pupils often dilated. 


Conjunctivae slightly in- 
jected ; pupils natural.- 



DIFFERENTIAL DIAGNOSIS. 



167 



TYPHUS FEVEE. 

No epistaxis. 

Skin has a pungent heat. 
Sometimes emits am- 
moniacal odor. 

Mulberry-rash. Eruption 
deep red, copious, ap- 
pears all over the body. 

Appears on 5th or 6th 
day. Each spot remains 
until the close of the 
disease. 

Temperature rises rapidly, 
reaches 104° or 105° at 
end of 2d day. 

Falls rapidly after the 
12th or 14th day. 



Pulse, soft, 100 to 140. 

Delirium and stupor, 
early and prominent. 



Abdominal symptoms ab- 
sent. 
Constipation. 
No tympanites. 



Emaciation slight ; great- 
er prostration. 

Pneumonia and bronchi- 
tis in finer tubes. 

Death often within 10 
days. 

Mortality, 15 to 50 per 
cent. 

No constant lesions. 



TYPHOID FEVEE. 

Epistaxis common. 

Skin sometimes bathed 
in acid perspiration. 
Musty odor. 

'• Eose-rash. " Eruption 
light red, thinly scat- 
tered, confined to chest 
and abdomen. 

Appears on 7th to 9th 
day. Each spot lasts 
3 days. 

Temperature rises 2° 
from morning to even- 
ing and falls 1° from 
evening to morning. 

Reaches 104° on morn- 
ing of 4th day. Re- 
turns gradually to the 
normal standard in 4th 
week. 

Pulse 100 to 140. 

Cerebral symptoms ap- 
proach gradually, and 
last longer. 

Abdominal symptoms 

prominent. 
Diarrhea,ty mpanites and 

gurgling. 
Tenderness in right iliac 

fossa. 
Emaciation great. 



Bronchitis and pleuritis. 

Death rarely within 14 
days, usually in or af- 
ter 3d week. Mortal- 
ity, 20 per cent. 

Constant lesions of ileum 
and mesenteric glands. 



EELAPSIXG FEVEE. 

Epistaxis occasionally, es- 
pecially at crisis. 

Skin is hot. Profuse 
sweat at the crisis. 



No defined rash. Some- 
times a rose eruption 
resembling roseola. 



Temperature rises rap- 
idly to 104° or even 
109°, within 24 hours. 

Falls suddenly during the 
remission. Rises rapid- 
ly during relapse to 
106° or 107°. 

Pulse, small, 140 to 160. 
Mind usually clear. 



Pain and tenderness in 

epigastrium. 
Constipation. 
Sometimes diarrhea at 

crisis. 

Emaciation not marked. 
Bronchitis common. 

A fatal termination is 
rare. 



Lesions not characteristic- 



168 LECTUKES ON FEVEES. 

A variety recognized by Niemeyer as gastric fever is occasion- 
ally mistaken for typhoid fever although it oftener simulates 
typho-malarial fever. It commences with headache, malaise and 
anorexia, followed by a slight chill, with marked gastric irrita- 
bility, nausea, vomiting and constipation. There is marked epi- 
gastric tenderness, and a peculiar sweetish or garlic-like odor to 
the breath, which is believed to be pathognomonic. The tem- 
perature rises at first to 100° Fahr. but falls below the normal as 
the disease advances. The pulse beats from 60 to 70 per minute. 
This variety of fever occurs more in women than in men, and 
oftener after the middle period of life. It differs from typhoid 
fever in that it has neither tympanites, diarrhea, delirium, sub- 
sultus tendinum, eruption, iliac tenderness, nor sordes. Its 
mortality is higher than that of typhoid ; and double vision or 
total loss of sight is considered a grave symptom. 

Acute tuberculosis is attended by many symptoms of typhoid 
fever. Its fever rise is, however, more sudden, for early in the 
disease, the temperature reaches 106° Fahr. or 107° Fahr. The 
rose-colored spots of typhoid are never present, and diarrhea 
rarely exists. And, generally, the abdomen, which is tympanitic 
in typhoid fever is flat or even spaphoid in acute tuberculosis. 

Influenza which at times closely resembles typhoid fever, may 
be differentiated by the short duration of the attack, the tempera- 
ture range, and the general absence of the abdominal symptoms 
of typhoid. 

Pneumonia with typhoid symptoms — typhoid pneumonia — 
maybe confounded with typhoid fever. In the former, however, 
there is no eruption, and the temperature curve is atypical. The 
typhoid symptoms appear usually during the second stage of the 
pneumonic inflammation, and are either preceded or attended by 
cough, and the characteristic expectoration. Physical explora- 
tion of the chest if instituted before the typhoid state supervenes 
will elicit positive evidence of pneumonic consolidation. 

In g astro-enteritis, which may be confounded with typhoid 
fever, the febrile movement is usually symptomatic, and preceded 
by diarrhea and vomiting. There is neither eruption, nor en- 
largement of the spleen. The temperature curve is atypical, and 
the disease is of a relatively shorter duration. 

Trichiniasis occasionally closely resembles typhoid fever. The 



PROGNOSIS. 169 

differential diagnosis rests chiefly upon the existence of intense 
muscular pains and oedema of the eyelids; as also on the ab- 
sence of epistaxis, the rose spots and enlargement of the spleen. 
A microscopical examination of the muscular tissue will render 
the diagnosis positive. 

Prognosis. — Typhoid fever is best endured by lean and mus- 
cular individuals. The prognosis is always bad in fat and gouty 
subjects, and in persons over forty years of age. It is especially 
unfavorable in the puerperal state, and when occurring among 
the intemperate. 

Death may occur at any period of the disease, but in uncom- 
plicated cases it rarely occurs earlier than the third week. It 
may take place by asthenia at the end of the third or in the 
fourth week. It may occur by coma at the end of the second or 
eai]y in the third week. Or it may follow sudden collapse after 
intestinal hemorrhage, perforation, or sudden heart failure, any 
time after the second week. Liebermeister says that in all 
typhoid patients who die without complications, the immediate 
cause of death lies in the fever and its consequences. The pa- 
tients die either from weakness of the heart, caused by the rise 
of temperature, or from paralysis of the brain. Abortive cases, 
those in which the pathological processes of the ileum do not 
go on to sloughing, terminate abruptly by crisis about the four- 
teenth day. Typical cases always terminate by prolonged lysis, 
defervescence being completed by the twenty-first or twenty- 
eighth day. A second attack of typhoid fever is usually milder 
than the first. 

The daily fluctuations in temperature are of great importance 
in making the prognosis. As a rule the greater the daily fluct- 
uations the more favorable the prognosis. But a sudden rise or 
fall in temperature at any period of the fever is of bad omen. 
Usually the more sudden the appearance of the disease, and 
the more rapid the temperature rise, the milder the attack. A 
continuously high fever is always more disastrous to the system 
than one marked by morning remissions. The temperature at 
the end of the first week is a guide for the coming weeks. A 
moderate elevation of temperature from 103° Fahr. to 105° Fahr. 
at this time indicates that the disease will probably run a favor- 
able course. After the first week a temperature above 105° 
Fahr., if prolonged, renders the prognosis unfavorable. Slight 



170 LECTURES ON FEVEES. 

decline accompanied by great fluctuation of temperature, during 
the third week, is a bad symptom. 

In giving the percentage of over four hundred cases observed 
in the hospital at Basle, Wilson writes, that of those m whom 
the axillary temperature did not attain 104° Fahr. 9.6 per cent 
died. Of those that reached or exceeded 104° Fahr. 29.1 per 
cent died. Of those that rose to or beyond 105°. 8 Fahr. over 50 
per cent died. And of those that exceeded 107° Fahr. nearly 
all died. 

The state of the pulse is an important element in prognosis. 
A full and regular pulse of 110 or 115 per minute, with a good 
heart impulse and a distinct first sound, renders the prognosis 
favorable, even if the temperature is high. "While a pulse of 120 
or 130, with a feeble impulse and an indistinct first sound, vitiates 
the prognosis. A sudden fall of the pulse from any cause is an 
unfavorable symptom; a sudden quickening is also an unfavor- 
able indication as it shows extensive cardiac failure. Cardiac 
weakness favors the formation of blood clots in the heart cavities, 
which breaking up may lead to embolism. Yenous thrombosis 
does not vitiate the prognosis, as it usually ends in recovery. 

In cases in which the cerebral symptoms are marked and 
severe, the prognosis should be guarded. Cerebral oedema, an- 
nounced by an enfeebling of the mental powers and a tendency 
to stupor, may appear as a complication during the third week, 
and always renders the prognosis grave. Cases characterized by 
persistent delirium usually terminate fatally. 

Intestinal hemorrhage, if slight, and occurring before the 
twelfth day, is regarded by some as beneficial, but if copious and 
occurring after the twelfth day, it is an unfavorable symptom. 
Perforation, which is more frequent amongst men than women, 
is a dangerous and usually fatal complication. 

Laryngitis may in protracted cases of this fever, by suddenly 
giving rise to oedema of the glottis, endanger life. Capillary 
bronchitis with its sub-crepitant rales, great dyspnoea and stringy 
expectoration, coming on after the second or third week, if at all 
extensive, is an unfavorable indication. OEdema of the lungs, 
as the result of failure of heart power, may appear suddenly, any 
time after the third week, and is of grave import. An extensive 
pneumonia — usually catarrhal — accompanied by irregular varia- 
tions in temperature, and developing any time after the third 



PROGNOSIS. 171 

week, is especially unfavorable. The chances of recovery may 
however, be good, notwithstanding the occurrence of pneumoni- 
tis, provided the inflammation is limited to one lung. 

Acute gastric catarrh, due to dietetic errors, and occurring after 
the fourth week, if at all severe, is an unfortunate complication, 
and lessens the chances for recovery. 

Cellulitis frequently complicates convalescence, and may cause 
death. Bed-sores may cause death, either from exhaustion, or 
from septic poisoning. Pregnancy and the puerperal state al- 
ways unfavorably influence the prognosis. And individuals with 
either pulmonary phthisis, or diabetes, run great danger, when 
taken sick with typhoid fever. 



LECTIJEE XII. 
Typhoid Fever.— (Continued). 

TKEATMENT. 

I shall to-day direct your attention to the management of ty- 
phoid fever. 

Before entering on the consideration of therapeutic measures, 
it may however, be well to say a few words concerning prevent- 
ive treatment. 

Prophylaxis. — The essential point in the prevention of the 
spread of typhoid fever, I would have you remember, consists in 
the proper treatment of the dejections of the sick. So success- 
fully can the spread of the morbific agent be prevented, that next 
to conducting your patient to a successful convalescence, it will 
be your highest duty to see to it that no new cases of fever arise 
by either direct or indirect infection from any patient under your 
care. "When the disease appears in your locality, you should, if 
possible, find out the cause of the infection, remove all those 
surroundings which favor the reproduction of the poison, and 
take immediate steps to correct whatever conditions lead to the 
pollution of drinking water or of the air. 

In order to destroy the germ, which is contained in the intes- 
tinal discharges, the dejections, before being thrown out, should 
be promptly and thoroughly disinfected. For this purpose a 
solution of chloride of zinc, 20 per cent, or a solution of carbolic 
acid, 5 per cent, or what is preferable, Piatt's chlorides may be 
used. Or after the evacuations have been received into a porce- 
lain bed-pan, the bottom of which has previously been covered 
with a thin layer of ferric sulphate, a quantity of crude muri- 
atic acid, equal to one-third or one-half the amount of the 
172 



PRINCIPAL REMEDIES. 173 

discharge should be poured over the fecal mass. In rural dis- 
tricts — where the disease most abounds — the disinfected dis- 
charges should be emptied into trenches dug anew for their re- 
ception, and carefully covered up. Care should be taken to locate 
these trenches a sufficient distance from wells or springs, so that 
drainage from them may not contaminate the water supply. In 
cities and in localities where the dejections are usually emptied 
into the ordinary water-closets or privy-vaults, the closets or 
vaults should be immediately flushed with some one of the disin- 
fectant solutions already enumerated. 

All the patient's body and bed linen, and especially such as 
have been soiled with the excreta, before being removed from 
the room (daily), should be thrown into a five per cent solution 
of carbolic acid, or some other disinfectant, and then immedi- 
ately washed. Piatt's chlorides should be sprinkled on the bed 
and about the room, and after the death or cure of the patient, 
charcoal should be burnt in the apartment with sublimed sulphur, 
and the room closed for twenty -four hours. Before the room is 
again occupied it should be washed with carbolized water, and 
freely aired for at least one week. 

When the disease is prevailing as an endemic, Baptisia, first 
dil. administered morning and evening, often acts as a preventive 
by rendering the system less susceptible to the morbific agent. 

Principal Remedies. — Typhoid fever being a self -limited dis- 
ease, it cannot be cut short , after tlie morbific agent has fully in- 
vaded the organism, by any known method of treatment. In ex- 
ceptional cases, if you are fortunate enough to be called to a pa- 
tient before the poison has fully invaded the organism — and that 
is before the appearance of any definite symptoms that will en- 
able you to diagnose typhoid fever — and are still more fortunate 
to have prescribed Baptisia or Bryonia, you may perchance assist 
the case to assume either the mild or abortive type. Otherwise, 
to use a nautical phrase, you must be content simply to steer the 
ship, for you can neither shorten nor alter the course of the storm. 

Baptisia may be justly considered our sheet anchor in the 
treatment of typhoid fever during the first week. For it is ca- 
pable of exciting a fever resembling that of typhoid, and of pro- 
ducing congestion and catarrhal inflammation of the intestinal 
mucous membrane, with abdominal tenderness and diarrhea, the 



174 LECTURES ON FEVERS. 

pathological condition present during this period. The soft and 
full, yet quick pulse, the headache and tendency to delirium, the 
despair of cure, the fetid breath, the soreness all over, and the 
intolerance of pressure on lying are marked symptoms. It is 
best indicated in that type which is characterized by extreme 
depression of vitality. And if administered early, it will con- 
siderably abate its energy. 

Bryonia is an older and more tried remedy than Baptisia. It 
is mainly useful in moderately severe cases, and is characteris- 
tically indicated for the symptoms prior to the stage of ulcera- 
tion. Nervous symptoms do not contra-indicate it, especially if 
there is mild delirium at night about the affairs of the previous 
day or business matters. Besides being adapted to the general 
symptoms of the early stages of the fever, this remedy has a 
specific action on the bronchial tubes. Sometimes it suffices, 
unaided, to bring the disease to a favorable termination. 

Rhus tox. is adapted to the more intense cases, and corresponds 
to all stages, but more especially to the period of fully developed 
intestinal affection. It supersedes Bryonia as soon as the charac- 
teristic stools appear, and is particularly indicated when the 
dejections are copious and of a cadaverous odor, when the tongue 
is brown and parched and presents the red triangular tip, and 
when the rheumatoid tearing pains in the joints are worse dur- 
ing rest. In whatever stage this remedy is indicated, the func- 
tions of vegetative life will be found excited and over-active, 
while those of animal life will be depressed. 

Arsenicum alb. takes the place of Rhus tox., when the latter 
fails to control the critical evacuations, and a graver erethitic 
state supervenes. It is especially useful during the second half 
of the second and during the third week. It is the remedy when 
the stools are dark in color and offensive, and when bed sores 
appear early in the disease. Frequent urging to urinate, with 
burning and scanty discharge is speedily relieved by its admin- 
istration. 

"When vegetative and animal life are simultaneously depressed, 
and in consequence of the excessive prostration the patient lies in 
a state of stupid apathy and indifference, Phosphoric acid is the 
remedy. At the onset of the disease you will often find it in- 
valuable in arresting the diarrhea, especially when the discharges 



PRINCIPAL REMEDIES. 175 

are yellow and watery, and the tongue is pale, moist, and thinly 
coated. It is an important remedy in mild typhoids attended 
with dullness of hearing and great nervous prostration. Lyco- 
jDodium preceded by a few doses of Calcarea carb\ is said to 
ameliorate the symptoms, when the eruption is delayed, and 
there are muttering delirium, carphologia, and tympanites. 

When symptoms of putrid decomposition of the "fluids appear 
you will think of Muriatic acid. It is the best remedy for the 
putrid sore throat which sometimes occurs as a complication. 
And it may occasionally be of service in hemorrhages from intes- 
tinal ulceration when Nitric acid fails. A sliding down in bed is a 
marked characteristic. The Mercuric cyanide may prove an 
efficient remedy when ulcerative changes, attended with great 
prostration, take place in the pharynx and larynx. Nitric acid 
will do good service when the evacuations consist of greenish 
mucus, and the tongue is thickly coated white. It is our main 
remedy in intestinal ulceration with hemorrhage, when the 
blood is fresh and of a bright red color. Profuse passive hem- 
orrhages call for Kreosoie or Hamamelis®. Terebiniliina should 
be substituted when with the hemorrhage from the bowels there 
is extreme tympanites, and retention of urine. Urinary reten- 
tion is best relieved by the catheter, which should be used when 
necessary twice a day. Our best remedy to prevent a recurrence 
of the retention is unquestionably Opium. 

Phosphorus supplements Phosphoric acid, and is indicated 
when the disease assumes an adynamic type. Its stools are pain- 
less, profuse, and either resemble flesh water or are black like 
coffee dregs. Frequently there is watery, bilious vomiting in 
the first and at the beginning of the second period. It frequent- 
ly arrests the preliminary diarrhea of the first week, and is in- 
valuable for colliquative diarrhea occurring as a sequel. Phos- 
phorus is an efficient remedy when Bryonia fails to relieve the 
catarrhal and pulmonary difficulties, and when, towards the end 
of the second period, there is a tendency to hypostatic consoli- 
dation, or pneumonia. Spongia will occasionally be of service 
when laryngeal symptoms predominate. Senega follows Tartar 
emet., in the treatment of the bronchitis, and is adapted to that 
passive form which is attended with copious secretion and a de- 
pressed state of system. Tartar emet. may prove useful when 
oedema of the lungs threatens, and there is great rattling of ac- 



176 LECTUEES ON FEVERS. 

cumulated mucus in the chest. Should the mucus accumulation 
at any time threaten to cause paralysis of the lungs and asphyxia, 
Moschus will be your best remedy. 

Mercurius dulcis may be useful during the second period, es- 
pecially when there is danger of perforation from deep ulcera- 
tion of the glands of Peyer. It may be given when the evacua- 
tions become more frequent at night, and are greenish or yellowish 
in color, provided the tongue, which is usually thickly coated, re- 
mains moist, and there is no delirium. When peritonitis occurs 
without perforation, you will think of Mercurius cor. In ex- 
treme cases, as your dernier resort, I may mention Carbo veg., 
— a remedy which will frequently render you excellent service, 
in overcoming that complete torpor of vital functions, which 
neither phosphorus, muriatic acid, rhus tox., nor arsenicum have 
the power to remove. Along with well-timed alcoholic stimu- 
lation, it may prove useful, if at any time the functional powers 
of the heart speedily fail. 

Belladonna may prove efficacious as an intercurrent remedy, 
when early in the disease the patient becomes delirious, sees all 
sorts of frightful phantasms, and no longer recognizes his friends 
and relatives. It is the remedy for the early bronchial compli- 
cations in children, and also for the pharyngeal spasms which 
occasionally occur later on in the disease. Hyoscyamus maybe 
needed when the delirium is continuous and does not yield to 
Belladonna. At any stage the occurrence of lascivious mania, 
on the one hand, or the sinking of the- patient into a state of 
apathetic stupefaction, on the other, is a strong indication for 
this remedy. In the higher degrees of delirium, Stramonium 
is frequently the appropriate remedy, especially when there is 
great loquacity, and a mania for light and company. Valerian 
sometimes comes to the rescue, when bell., hyosc, and stram., 
all fail. 

Opium will be of service when there is considerable stupor 
and but little fever, or when mild delirium alternates with stu- 
por or stertorous breathing. It is the first remedy you will 
think of when sopor threatens to terminate in paralysis of the 
brain, and if it fails, Lacliesis may cause the desired reaction, 
especially if with the soporous condition there is dropping of 
the lower jaw. When the stupefaction is attended with involun- 
tary discharges of stool and urine Arnica may be compared. 



LEADING INDICATIONS. 177 

Occasional intercurrent remedies are: Merc, sol or Ledum for 
the epistaxisin the first period. Phosphorus for epistaxis in the 
later periods. Bell, or Merc, viv. for the parotitis. Laurocera- 
sus for the clonic convulsions of the limbs. Veratrum alb., if 
weakness remains after the critical periods have passed. Carbo 
veg. y Fluoric acid., or Secale for the bed sores. Coccidus for 
loss of appetite, Cinchona for excessive hunger, and Nux vom. 
for indigestion, during convalescence. And Psorinum, Alstonia 
or Sulphur for protracted convalescence. 

Leading Indications. — The guiding symptoms for these our 
main remedies in typhoid fever, as well as for others occasion- 
ally of service, may be compiled as follows : 

Agaric us muse. — Disinclined to answer questions (phos. acid). 
Desire for alcoholic drinks. Sensitive smell (colch.). Dry 
tongue with dryness and constriction in the fauces. Humbling 
in the bowels with the passage of much inodorous flatus. Tremor 
of the hands. Aching along the spine and limbs. Pains in the 
legs especially in the hip joints. Twitchings of the gluteal 
muscles. Cramps of the hands and feet. 

Apis. mel. — Muttering delirium. Sopor interrupted by pierc- 
ing shrieks. Tongue swollen, dry, cracked, ulcerated, and pro- 
truded with difficulty (ars., rhus). Great soreness in the pit 
of the stomach when touched (bry.). Swollen abdomen, sore 
to the touch (lach.). Stools occur with every motion of the 
body (phos.). Suppression of urine (hyos.). White miliary 
eruption on the abdomen. Tired, feeling as if bruised in back 
and limbs (rhus.). Carbuncles with burning, stinging pains 
(cws.). Great weakness, and sliding down in bed, (mur. acid.). 

Arnica. — Patient sits in a semi-stupid state. Appears to be 
absorbed in deep thought yet thinks of nothing. Forgets the 
word while speaking (baryta, rhus ). Declines to answer ques- 
tions (phos. acid ) Thinks he is well (ars.). Confused feel- 
ing in the head with pressure over the right brow. Unrefresh- 
ing sleep with anxious dreams. Muttering, and loud blowing 
during expiration. Delirium. Stupor. Great weariness, and 
prostration, A bruised, sore feeling, the bed feels too hard 
(bapt). Epistaxis. Trembling of the lower lip. Tongue 
coated white, or dry with a brown streak in the middle (bapt). 
Taste, breath and perspiration offensive. Abdomen distended. 



178 LECTUEES ON FEVERS. 

Involuntary discharges of urine and faeces (ars.,hyos.). Vio- 
lent stitches in the middle of the left chest (bry.). Lassitude 
and sluggishness of the whole body. Great sinking of strength, 
Petechia. Ecchymoses. 

Arsenicum alb. — Great restlessness and anxiety. Constant 
motion of the head and limbs. Drawing pressive pain in the 
right side of the forehead. Deathly color of the face (carbo 
veg.). Cachectic look, sunken hippocratic countenance (ver. 
alb.). Grinding of the teeth (hell., hyos.). Dropping of the 
lower jaw (lack.). Circumscribed redness of the cheeks. Hard- 
ness of hearing. Lips dry and cracked and covered with sordes. 
Tongue red, dry and cracked (bry., rhus ). Black leather-like 
tongue. Dryness of the mouth with violent thirst. Drinks 
of ten, but little at a time (bell., opp. bry.). Unintelligible ar- 
ticulation as if the tongue was too heavy (carbo veg.). Intense 
burning pains in the stomach and pit of the stomach (plios., 
ver at. alb.). Violent and incessant vomiting. Meteoristic dis- 
tension of the abdomen with gurgling (lycop., hyos., terebinth.). 
Ileo-csecal region sensitive to the touch (mere, plios. acid ). 
Brownish or watery, fetid, involuntary stools. Involuntary mic- 
turition (hyos.). lie tent ion of urine. Voice weak, trembling, 
hoarse. Difficult breathing with great anguish. Very tenacious 
mucus in the chest (tart, emet., kali bich.). Extensive pul- 
monary hypostasis. Pulse frequent, hard and tense, or small, 
trembling and intermittent. Irregular action of the heart, ab- 
sence of the second sound. White miliary eruption (lach., 
mur. acid). Petechia (rhus, secede, am.). Boils (mere, 
sil., sul.). Bed-sores (carbo. veg., fluoric acid ). Great weak- 
ness and prostration. Bapid emaciation (secede). (Edematous 
swelling of the feet. Cold clammy sweat. Cadaverous odor. 
Bose-colored spots on the chest and abdomen. Symptoms worse 
from 1 to 3 A. M. 

Arum triph. — Lips and corners of the mouth sore, cracked 
and bleeding. Swelling of the submaxillary glands and neck. 
Tongue sore, red, with elevated iDapilke. Fetid breath. Excess- 
ive salivation. Boring of the nose. Great restlessness, desires 
to escape, although perfectly conscious of what he is doing, and 
of what is said to him. 

Baptisia. — Confusion of ideas (gels.). Great nervous rest- 



LEADING INDICATIONS. 179 

lessless. Cannot s'eep because the head feels scattered about 
and she cannot get the pieces together. Stupor. Heavy sleep, 
the x^atient can scarcely be aroused long enough to answer a 
question. Falls asleep in the midst of attempted answers 
{arnica, hyos.). Face dark red with a besotted expression. 
Head and face feel numb. Sordes on the teeth and lips. Mouth 
and tongue very dry. Fetid breath. Tongue swollen and 
thick. White furred tongue with red edges. Yellow or yellow- 
ish-brown coating along the center of the tongue. Bitter, flat or 
putrid taste in the mouth. Fetid, exhausting stools (ars.). 
Fetid, dark red urine. Tired, bruised, sick feeling in all parts of 
the body. Feeling as if the lower limbs were severed from the 
body {opium). Sensation as of a second self alongside in 
bed. Patient changes position frequently because the bed be- 
comes too hard (arnica ). 

Belladonna. — Starting, jumping during sleep. Sleepiness 
"but cannot sleep (lach., opium). Yiolent delirium. Constant 
desire to spring out of bed (hyos.). Attempts to bite, strike 
and spit at the attendants (hyos., opium). Yiolent throbbings 
in the brain. Throbbing of the carotids (glon.). Pressive pain 
id the forehead, obliging him to close the eyes. Sparkling, star- 
ing eyes (hyos., stram,). Intolerance of light and noise. Face 
red, swollen and hot. Dryness of the mouth, tongue and throat. 
Tongue red at the edges and white in the center (gels. ). Trem- 
bling and heaviness of the tongue with thick speech (lach.). 
Fluids escape through the nose (kali bich., lach.). Sore throat, 
or a feeling as of a lump in the throat which induces hawking. 
Tenderness of the abdomen aggravated by the least jar. Reten- 
tion of urine. Involuntary urination. Dry spasmodic cough, 
worse at night (dros., hyos.). Pains come and go suddenly. 
Starts as if in affright on awaking or during sleep. 

Bryonia. — Exceedingly irritable and inclined to be angry 
{chain.). Easily offended. Wants to go home. Hasty speech 
(heparsul.). Yiolent, oppressive, stupefying headache. Yertigo 
with sensation as of the head turning in a circle (bell.). Yisions 
when closing the eyes. Nightly delirium, especially about the 
affairs of the previous day or business matters. Buzzing in the 
ears with hardness of hearing. Nose-bleed, especially in the 
morning on rising. Face red, hot and puffy. Lips dry, brown 



180 LECTURES ON FEVEES. 

and cracked. Tongue thickly coated white (mere.) or yellowish.. 
Dry feeling in the mouth. Intensely bitter taste (mix). Ex- 
cessive thirst; drinks large quantities at a time. Nausea, or 
even vomiting, after every meal. Cannot sit up from nausea and 
faintness. Yomiting first of bile, then of fluids (opp., not. mur.). 
Epigastric region painful to touch and pressure (ars., mix)., 
Acute pains in the ileo-csecal and splenic regions. Offensive 
stools. Dark, almost brown urine. Dry hacking cough, with 
stitches in the chest and region of the liver (bell, mere). Full, 
hard and rapid pulse. Pain in the back and limbs when mov- 
ing. Restless sleep, with moaning, and with chewing motions. 
Great weakness and exhaustion. 

Calcarea carb. — Great anxiety with palpitation of the heart. 
(cact, spig.). Yertigo. Heaviness in the forehead. Hard- 
ness of hearing. Epistaxis, especially in the morning (bry.). 
White coating on the tongue (mere). Sleeplessness from same 
idea arousing him from slumber. Abdomen hard and distended. 
Soreness in chest on inspiration. Short hacking cough. Ex- 
cessive diarrhea. Eavenous hunger, or else loss of appetite. 
Profuse sweat every morning, and from the slightest exertion. 
Great weariness of the limbs as after a long walk. Tendency to 
obesity. 

Camphor. — Sudden and great sinking of strength (ars.). 
Extreme restlessness and anxiety (ars.). Cold sweat all over 
(verat. alb.). Cold, pointed nose. Face pale and anxious. 
Coldness of the limbs (ars., verat.). Cramps of the calves 
(sulph.). Small, weak, scarcely perceptible pulse (carboveg.). 
Yiolent delirium. Dullness and heat of the head with cold, clammy 
skin. Tongue cold (carbo veg., verat alb.). Great thirst. Boil- 
ing and rumbling in the bowels with involuntary evacuations. 

Carbo veg. — Restlessness and anxiety. Greenish color, or 
great paleness of the face (ars.). Hippocratic countenance 
(verat. alb.). Severe nose-bleed several times daily. Dullness 
of the eyes, pupils insensible to light. Loss of hearing. The 
gums are painfully sensitive while chewing. Cold breath and 
tongue. At times the tongue is moist and sticky. At others it 
is dry and cracked. Hawking of mucus in the throat. The epi- 
gastric region is distended. Frequent and violent eructations 
(puis.). Flatulent distention of the abdomen. Emission o£ 



LEADING INDICATIONS. 181 

large quantities of offensive flatus. Colliquative diarrhea, putrid 
and involuntary (ars.). Diarrhea during convalescence. Bron- 
chial catarrh with difficult expectoration of tenacious mucus. 
Loud rattling in the chest. The pulse is thread-like and scarcely 
perceptible. Coldness of the surface. Cold sweat on the limbs. 
Cold breath. Threatened paralysis of the lungs and heart. Bed 
sores (ars., fluoric acid, secede). 

Cinchona. — Sense of internal illness as of impending disease. 
Frequent nose-bleed, especially in the morning (bry.). Pale, 
earthy, grayish-yellow complexion (ars.). Constant inclination 
to stretch the limbs or change position. Enlargement of the 
liver and spleen. Bitter or sour taste. Empty eructations. 
Milk deranges the stomach (sulph.). Tympanites. Painless, 
indigested stools (podo.). Profuse sweat during sleep, espe- 
cially on the side on which the patient lies. Great weakness. 
Protracted convalescence. 

Cocculus. — Slowness of comprehension. Very sensitive mood. 
Tertigo with nausea when rising up in bed (bry. ) must lie down. 
Stupor. Coma vigil. Heaviness of the lids. Noise in the ears 
like the rushing of waters. Metallic, coppery taste with loss of 
appetite (ars., rhus). Xausea with tendency to faint. Drink 
rolls audibly down the throat (hydr. acid ). Great distention 
and rumbling in the abdomen. Weakness of the cervical mus- 
cles. Feet and hands fall asleep alternately. Great general 
weakness and weariness after over-exertion. 

Colcliicnm. — External impressions, especially strong odors, 
disturb the patient. Dullness of perception. Delirium with 
headache (bell.). Sudden sinking of the vital forces. Cadaverous 
appearance. Hollow staring eyes. Lips, teeth and tongue covered 
with sordes. Skin dry. Xose-blee 1 evenings. Body hot. Hands 
and feet cold. Cold sweat on forehead. Tongue, heavy, stiff 
and insensible ( con.). Tongue protruded with difficulty. Grind- 
ing of the teeth (hell,, hyps.). Epigastrium extremely sensi- 
tive to pressure (bell.). Yiolent burning or icy coldness in the 
stomach (ars.). Great thirst. Distention of the abdomen. 
Watery diarrhea. Involuntary stools. Dark, liquid, offensive, 
painful stools. Suppression of urine. Involuntary micturition. 
Irregular intermittent respirations. Small, quick, scarcely per- 
ceptible pulse. (Edematous swelling of the legs and feet (ars). 



182 LECTURES ON FEVERS. 

Great exhaustion and weakness as after exertion, in the 
autumn. 

(jelsemium. — In the prodromic period. Dullness of the men- 
tal faculties (bapt). Trembling from weakness. Vertigo and 
blurred vision (iris vers.). Drowsiness, vertigo, and great 
muscular prostration. Heaviness of the head, relieved after 
profuse emission of watery urine (jrfios. acid). Severe pains 
in the head, back and extremities. The brain feels as if bruised 
(bell.). Head feels as "big as a bushel." Cephalalgia with 
aching lancinating pains extending from the left occipital region 
through the head to the forehead and eyeballs. Drooping of 
the eyelids (caust). Heavy, besotted expression (bapt). Crim- 
son Hush of the face. Tongue coated yellowish-white. Can 
hardly protrude it, it trembles so (bell., lach., secale). Numb- 
ness of tongue, feels so thick, can hardly speak (caust). Iliac 
tenderness. Chilliness. Coldness of the hands and feet. Com- 
plete prostration of the entire muscular system. 

Hamamelis. — Great lassitude and weariness of the limbs. 
Extreme soreness of the abdomen. Bloody alvine dejections of 
tar-like consistency (alumen, black). Profuse nose-bleed with 
feeling of tightness of the bridge of the nose (dulc). 

Helleborus nig. — Sensation of soreness of the back part of 
the head with stupefaction. Eyes vacant, pupils dilated ( bell. y 
hyos.). Insensibility. Slow of comprehension. Lies in a state 
of constant slumber. Utters no complaint. Chewing motions 
of the jaws ( bry. ). Convulsive twitching of the muscles ( cupr. ). 
Sliding down in bed (mur. acid). Small, slow, tremulous pulse. 
Trifling loss of flesh. 

Hyoscyamus. — Complete loss of consciousness (bell., opium). 
Coma vigil. Muttering with picking at the bed-clothes (opium). 
Muttering loquacity (apis). Answers questions correctly, when 
asked, but lapses again into delirium (arnica, bell.). Whines 
and don't know why. Inability to direct the thought. Sleep- 
lessness or constant muttering sleep. Constant delirium with 
great restlessness. Jumping out of bed. Thinks he is in the 
wrong place. Attempts to ran away (bell., bry.). Desires to 
uncover and remain naked. Flushed face, stupid expression 
(bapt). Eed, staring, sparkling eyes (bell.). Pupils dilated 
(bell. } and insensible (opium). Objects appear red as fire, oi 



LEADING INDICATIONS. 183 

too large ( opp.pZal). Deafness. Constrictive sensations in the 
throat with inability to swallow (bell, stram.). Clean, parched, 
dry tongue. Much thirst. Hiccough. Putrid breath. Invol- 
untary stools at night (ars., rlius). Eetention of urine. In- 
voluntary urination. The urine leaves reddish streaks on the 
sheet (hjcop.). Grating of the teeth (apis, hell ). Trembling 
of the limbs. Subsultus tendinum (j)hos. acid). Rose spots 
on the chest and abdomen. 

Ignatia. — Great impatience. Changeable disposition. Sen- 
sation as if swinging to and fro in a swing. Broods over im- 
aginary troubles. Flickering zigzags before the eyes. Frequent 
sighing. Over-sensitive to pain (coffea). Sour taste in the 
mouth. Convulsive motions of the face and extremities (stram.). 
Single jerks of the limbs on falling asleep. Troublesome dreams 
of one and the same thing, all night. Palpitation of the heart. 

Lacliesis. — Great mental and physical exhaustion. Sleepi- 
ness, but unable to sleep. Sleep, followed by aggravation of all 
the symptoms. Stupor and muttering (apis). Loquacious, 
constantly changing from one subject to another. Thinks she is 
dead. Sunken countenance. Dropping of the lower jaw ( hjcop., 
opium). Tongue dry, red or black, cracked and bleeding (ars. ). 
It trembles when protruding it (gels., bell). Inputting out the 
tongue it catches on the teeth or under lip. Lips dry, cracked 
and bleeding. Appetite variable. Desire for oysters (lye). 
Hyperesthesia of the abdomen. Offensive stools. Intestinal 
hemorrhage containing flakes and granules of decomposed blood. 
Dyspnoea. Hawking of mucus with rawness in the throat. 
Superficial ulcers (mere., nit. acid) of a blackish-blue appear- 
ance. Falling off of the hair (mere, nit. acid., plws.). In the 
spring. 

Laurocerasiis. — Irregular beating of the heart with slow 
pulse (digit.). Clonic spasms of the extremities (canth.). \Vant 
of energy of the vital powers, and want of reaction. 

Lycopodium. — Depression of spirits (not. puis,). Great fear 
of being left alone. Uses wrong words to express an idea 
(arnica, anacardium, graph.). Restless sleep. Subsultus ten- 
dinum. Earthy color of the face. Circumscribed redness of the 
cheeks. Face suddenly yellow or pale after the first week (gen- 
erally fatal). Putrid smell from the mouth. Tongue coated 



184 LECTUKES ON EEVEKS. 

white, or else red and dry. Vesicles on the tongue. "When the 
tongue is spasmodically thrust to and fro between the teeth. 
The lower jaw drops {opium, mur. acid., lack. ). Fan-like motion 
of the alse nasi. Desire for sweet things. A little food seems 
to fill the stomach full, and causes fullness and distention of the 
abdomen. Bowels much distended with rumbling in the left 
hypochondrium. Chilliness in the rectum before stool. Urine 
leaves a red, sandy stain on the sheet (cinch., phos.). Shortness 
of breath. Cough with scanty, gray, salty expectoration. Cold- 
ness of the hands and feet. One foot hot and the other cold. 
Falling out of the hair ( graph., mere, phos. ). The hair becomes 
gray early. Nervous debility. Emaciation. 

Mercurius. — Heaviness of the head with great inclination to 
sleep. Answers questions slowly. Great weariness and pros- 
tration. Trembling. Pale, earthy-colored, puffy face (ars., 
puis.). Eyes dull. Tongue swollen, soft and flabby, taking im- 
pressions of the teeth on its edges. Putrid odor from the mouth. 
Region of the liver painful and sensitive to contact (bell., bry.). 
Yellow-green stools. Bilious, slimy or watery diarrhea. Abdo- 
men hard, distended and painful. Inguinal glands swollen or 
suppurating (nit. acid). Frequent urination. Urine leaves a 
whitish sediment. Clammy perspiration at night. Icteroid hue 
of the skin. Nose-bleed during sleep. Sudamina. 

Muriatic acid. — When decomposition of the fluids is slow and 
extensive. Continuous delirium. Yivid hallucinations. The 
patient is busied with past and present events. Forgetful of 
time and place. Irritable. Sleepiness in the daytime, sleep- 
lessness at night with muttering delirium. Constant inclination 
to slide down in bed. Photophobia. Glistening eyes, con- 
tracted pupils. Over-sensitive to sounds. Acuteness of taste 
and smell. Excessive dryness of the lips, mouth and tongue. 
Tongue heavy, like lead, preventing talking. The lower jaw 
hangs down. Great thirst. Watery diarrhea mixed with lumps 
of whitish mucus. Involuntary stools while urinating. Profuse 
discharge of clear acid urine. Pulse rapid and very feeble, in- 
termits every third beat (fourth beat, nit acid). Respirations 
accelerated. Excessive prostration. Painless, rapidly spread- 
ing, indolent bed-sores. In low fevers. 

Nitric acid. — Irritable and excitable. Anxiety with fear of 



LEADING INDICATIONS. 185 

death (ars.). Frequent pains in all parts of the body, suddenly 
appearing and disappearing. Pale, yellowish complexion. 
Putrid smell from the mouth (mere). Appetite for chalk, lime 
and earth (alumina). White coating on the tongue. Ulcers in 
the mouth and fauces. Accumulation of mucus in the throat. 
Great sensitiveness and distention of the abdomen. Intestinal 
hemorrhage. Green, slim} T , acrid, fetid evacuations. Battling 
cough with purulent expectoration. Brownish, bloody sputa. 
Pulse irregular, intermits every fourth beat (third beat, mur. 
acid). Ulcers with stinging, pricking pains as from splinters. 
Emaciation, especially of the arms and thighs. Profuse falling 
off of the hair (graph., not. mur., pJws.). After the abuse of 
mercury. 

Nux moschata. — Fitful mood. Loss of memory (anac.,phos. 
acid). Difficult comprehension (am.carb.). Great drowsiness. 
Dryness of the mouth, tongue, and lips, with taste as after eat- 
ing strongly salted food. Little or no thirst. Polling, rum- 
bling or gurgling in the abdomen (aloes). Colic, relieved by hot 
wet cloths. Thin, yellow diarrhea like stirred eggs. Offensive 
colliquative diarrhea. Small, slow pulse. Great languor and 
excessive muscular restlessness. 

Nux vomica. — Over-sensitiveness to external impressions 
{cinch.). Delirious phantasies on lying down. Chilliness on 
slight movement. Dryness of the mouth and tip of the tongue. 
Flatulent distention of the abdomen after eating (ci)ich., lycop.). 
Desire for fat food. Hunger with aversion to food (opium). 
Alternate constipation and diarrhea. Intestinal cramps. Great 
desire to sit or lie down. Emaciation. Chlorosis. 

Opium. — Drowsiness or sopor. Complete loss of conscious- 
ness (hyos.) with slow stertorous breathing. Stupid sleepless- 
ness with frightful visions. Suffocating nightmare. Muttering 
delirium. Attempts to escape (bell., hyos.). Contracted pupils 
hyos.). Glassy, half-closed eyes. Face, dark red, bloated, hot 
(bell.), flushed (hyos.), or pale and sunken. Bed feels hot, can 
hardly lie on it. Violent thirst. Irregular respirations. Deep 
snoring, slow, breathing with mouth wide open. Convulsive 
movements and numbness of the limbs. Involuntary, offensive 
stools (ars.). Dark, fluid, frothy evacuations. Violent griping, 
cutting pain in the abdomen. Betention of urine. Dropping 



186 LECTUKES ON FEVEKS. 

of the lower lip and jaw (lack., mur. acid). Profuse sweat. 
Coldness of the extremities. 

Phosphorus. — Constant sleepiness. Low, muttering delirium 
(am., bapt, rhus). Coma vigil. Inability to concentrate 
thought (am., rhus). Carphologia (am., liyos.). Contracted 
pupils (opium, physostigma). Pale, sallow or changeable color 
of the face. Dry, immovable tongue, cracked and covered with 
sordes (ars., verat alb.). Thirst, with desire for very cold drinks. 
Burning in the stomach ( ars. ). Regurgitation of food in mouth- 
fills. Drinking causes rolling and rumbling in the abdomen. 
Sensation of weakness and emptiness in the abdomen (sepia). 
Vomiting of watery, bilious and slimy masses with great pain 
in the first and at the beginning of the second week, relieved for 
a time by ice, or very cold food or drink. Painless diarrhea, with 
abdominal distention and loud rumbling (cinch.). Watery, 
greenish, sago-like, or bloody evacuations, worse after eating. 
Typhoid pneumonia. Hard, dry cough with violent oppression 
of the chest, and difficult respiration. Difficult expectoration of 
tenacious mucus, or of mucus streaked with blood. Cough worse 
from evening to midnight (carbo veg., puis.), and when talking 
(dros.). Loud mucous rales in the lower lobes (ipecac, tart, 
emet.). Hepatization of the lungs. Small, quick, easily com- 
pressed pulse. Dullness of hearing, especially of the human 
voice. Profuse epistaxis. Eose spots and ecchymoses. Great 
emaciation. Weakness in the extremities, as if paralyzed. 

Phosphoric acid. — Indifferent. Disinclination to talk (pJios. 
opp. st ram.). Incapacity for thought (gels.). Answers ques- 
tions slowly and reluctantly, or short and incorrectly (phos.) 
Somnolency with muttering delirium. Pale, sickly complexion. 
The eyes are either dim or glossy. Hemorrhage from the nose 
of dark blood (ham.). Intolerance of musical sounds (caust.) 
Deafness with roaring in the ears. Dryness of the mouth and 
throat without thirst (nux). Grayish coating on the tongue. 
Desire for juicy things (puis.). Pressure in the stomach after 
eating. Meteoristic distention of the abdomen with rumbling 
and gurgling. Involuntary stools. Thin, whitish-gray evacua- 
tions. Dry, tickling cough. Frequent emission of pale, watery 
urine, forcing a milky-white cloud, especially at night. Fre- 
quent, small, feeble pulse. Dry, clammy skin. Bluish-red spots 



LEADING INDICATIONS. 187 

on the parts upon which the patient lies. Profuse night and 
morning sweat. In young persons who have grown very rapidly. 

Psorinuni. — Loss of memory during convalescence. De- 
spairing, melancholic mood (mix). Deep-seated, heavy pain in 
the region of the liver. Dark, brown, fetid stools. Cough with 
difficult green mucous expectoration. Great debility (sulph.). 
Profuse perspiration from the least exertion, and at night (cinch., 
phos.). 

Pulsatilla. — Peevishness, or inclination to weep. Dullness 
with pressive pain in the forehead. Restless sleep with sensa- 
tions of heat. Chilliness. Yivid, frightful, anxious dreams. 
Offensive odor from the mouth. Dryness of the tongue, as if 
burnt, without thirst (mag. mur.). Tenacious mucus in the 
mouth. Constant spitting. Bitter taste (try.). Distress in the 
stomach an hour after eating (nux.). Pulsation in the epigas- 
trium. Gnawing in the stomach as from hunger. Loud and 
painful rumbling and gurgling, especially at night. Emission 
of fetid flatus. Watery diarrhea, preceded by rumbling, worse 
at night. Great weariness and prostration. Wandering pains 
(kali bich.). 

Rhus tox. — Great restlessness and uneasiness (ars.). Con- 
fusion and dullness, with vertigo. Incoherent muttering. An- 
swers questions correctly but slowly (bry., hepar.). Active de- 
lirium and great prostration. Yivid, troublesome dreams of ex- 
cessive bodily exertion. Headache, worse from opening and 
moving the eyes (puis.). Pale, sunken face with blue rings 
around the eyes. Dark, livid redness of the cheeks. Epistaxis, 
morning or night. Dry, red, cracked tongue (bapt, bell). Red- 
ness of the tip of the tongue in the shape of a triangle. Putrid 
taste and breath. Induration of the parotid and sub-maxillary 
glands. Sordes. Great thirst for cold drinks, especially cold 
milk. Nausea. Copious, thin, yellow evacuations, worse at 
night. Involuntary, fetid stools, during sleep. Dry, tickling 
cough, worse in the evening and before midnight. Infiltration 
of the lower lobes of the lungs. Severe cough with tough, 
bloody expectoration. Soreness as if beaten in the hypochon- 
dria. Aching pains in all the limbs; must constantly change 
position. 

Secale corn. — Constant sighing. Hiccough (ars., nux mos.)^ 



188 LECTURES ON FEVERS. 

Great prostration and extreme restlessness. Aversion to being 
covered. Anxiety and burning at the pit of the stomach (ars.). 
Fear of death. Cold perspiration on the face and forehead. 
Sweat from the head to the epigastrium. Face, pale and sunken. 
Unquenchable thirst. Desire for sour drinks, especially lemon- 
ade. Painless, muco-bilious vomiting, with great prostration. 
Ravenous hunger. Thin, olive-green stools. Involuntary evac- 
uations. Suppression of urine. Great trembling when at- 
tempting to move. Fuzzy feeling in the extremities. Cold, blue, 
;shrivelled skin. Extensive ecchymoses. Bed-sores. 

Silicea. — Disposition to boils. Periostitis of the sacrum. 
Ulcers with stinging, sticking, burning pains (ars., lack.). Weak- 
ness and sense of great debility. Perspiration on the slightest 
exertion (sepia). Sensitive to cold air, takes cold easily. Ema- 
ciation. 

Stramonium. — Stupid indifference (phos. acid). Loquacious 
delirium (lach., lachnanthes). Furious delirium, worse from 
looking at shining objects. Tries to escape, struggles to get out 
•of bed (bell., rhus). Wide open, staring eyes (bell, hyos.). 
Transient loss of sight, hearing and speech. Oblique vision. 
Dryness of the throat. Violent thirst, especially for sour drinks 
(bry., secale). Yellowish-brown coating on the tongue which is 
dry in the center (bapi.). All food tastes like straw (sulph.). 
Black stools which smell like carrion (ars., carbo veg.). Hard, 
tympanitic abdomen. Suppression of urine. Involuntary urina- 
tion. Constant restlessness, with jerking motions of the limbs 
and of the whole body. Carphologia. Subsultus tendinum. 

Sulphur.— Anxiety in the evening, with inability to sleep at 
night. Weakness of memory, particularly for names. Hea,t, 
fullness and pressure in the forehead. Hardness of hearing 
(caust.). Weakness of the chest when talking (phos., stem.). 
Dyspnoea. Short, dry, nocturnal cough. Anorexia or else 
ravenous hunger, particularly about 10 or 11 A. M. Stomach 
feels distended after eating only a little (lye). The abdomen 
is painfully sensitive to the touch (bell.). Morning diarrhea 
with great prostration. Offensive, turbid urine (lach.). 

Sulphuric acid. — Irascibility. Hardness of hearing (calc, 
carb., sulph. ). Deathly paleness of the face. Dry, red or brown 
tongue. Aphthae. Swelling and inflammation of the sub-max- 



LEADING INDICATIONS. 189 

illary glands. Yiolent hiccough. Dark, persistent hemorrhages. 
Blue, ecchymotic spots (carbo veg., mix mos., phos. acid). 
Shortness of breath. Great weakness and prostration. 

Tartar emet. — Irresistible inclination to sleep. Trembling 
of the whole body. Pale, sunken face. White pasty coating on 
the tongue. Tongue red in streaks and dry in the middle ( rlnis). 
Continuous anxious nausea. Yiolent and painful urging to 
urinate with scanty or bloody discharge (can. sat). Great rat- 
ling of mucus in the chest (ipecac). Threatened oedema of the 
lungs (moschus). 

Terelbinthina. — Stupefaction. Coma (opium). Excessive 
prostration. Dry, smooth, glossy tongue. Tympanites. Fetid 
stools. Intestinal hemorrhage. Quick, small, thready, almost 
imperceptible pulse. Occasional subsultus tendinum. The 
urine is scanty and has the odor of violets. 

Yeratrum alb. — Sudden sinking of strength. Hippocratic 
countenance. Cold perspiration, especially on the forehead. 
Sunken eyes. Pointed nose. Tongue cold (carbo veg.), or 
coated white with red tip and edges. Yiolent thirst for cold 
water (ars., phos.). Excessive hunger for fruits, acids or salt 
things. Yiolent vomiting and wa eery diarrhea. Oppressive and 
spasmodic contractions of the chest. Cold breath. Suppression 
of urine. Icy coldness of the hands and feet. Continued pro- 
found sleep. The patient remembers events only as dreams. 

Yeratrum vir. — Muttering delirium. Restless sleep, with 
dreams of being drowned. The eyes remain open and the pupils 
are dilated. The face is flushed or else pale and covered with 
cold perspiration. The tongue is coated white or yellow, with a 
red streak down the center. The pulse is irregular, hard and 
frequent, and the heart beats rapidly when turning over in bed 
(bell.). Oppression of the chest, with slow, labored breathing. 
Dark, turbid, fetid urine. Involuntary micturition. Hiccough. 
Subsultus tendinum. Carphologia. 

Zincum. — Weakness of memory (anac). Unconsciousness. 
Brain exhaustion. Delirium with attempts to get out of bed 
(liyos. ). Constant jerking of the whole body during sleep. Car- 
phologia. Subsultus tendinum. Sliding down in bed (mur.. 
acid). Involuntary evacuations. Bed-sores. 



190 LECTURES ON FEVERS. 

HYGIENIC AND DIETETIC TREATMENT. 

In the treatment of typhoid fever it is highly important that 
the patient be properly hygiened and fed. 

As soon as the disease is suspected the patient should be 
ordered to bed, and not permitted to leave it until some days 
after complete convalescence. Absolute mental and bodily rest 
is a primary necessity. And in every case the use of the urinal 
and bed-pan to receive the evacuations from the bladder and 
bowels should be rigidly insisted upon. The sick-room should 
be large and well ventilated, and situated as remote as possible 
from the original source of infection. The temperature of the 
room must be kept below 60° Fahr. All superfluous articles of 
furniture should be removed from the apartment. The patient 
should lie on a mattress — never on a feather bed — with a linen 
sheet and a woolen blanket as a covering. The bed and body 
linen should be changed daily, and immediately thrown into a 
vessel containing a solution of carbolic acid, before being re- 
moved from the room. The bed and room should be sprinkled 
with Piatt's chlorides, and the water-closet must be frequently 
disinfected. The loom should be kept perfectly quiet. Visita- 
tions must not on any account be indulged in during 'the course 
of the fever, and to but a limited extent during the early days 
of convalescence. The position of the body should be frequently 
changed, and when sordes collect upon the teeth they may be re- 
moved by the use of a soft wet towel. Pieces of ice allowed to 
dissolve in the mouth will to some extent limit the formation of 
sordes. 

Tympanites is constantly present in typhoid fever, but if at 
any time it becomes great, and the accumulation of flatus in the 
colon is excessive, it may be necessary to carefully introduce into 
the bowel an intestinal tube to remove part of the accumulated 
gas. When intestinal hemorrhage occurs an ice bag filled 
with broken ice may be applied to the abdomen. The food at 
such times should be limited to meat essence, wine-whey or 
koumyss, and must be taken ice cold. Meat essence is prepared 
by cutting a pound of fresh lean beef into small pieces, and put- 
ting it into a pint bottle without water. It is then corked loosely, 
and the bottle immersed to its neck in cold water in a stewpan. 
Bring the water to a boil, and let it boil for two hours. Then 
pour off the essence without filtering. When there is great abdom- 



HYGIENIC TREATMENT. 191 

inal tenderness, thinly spread mush or flax-seed poultices, well 
smeared with lard, are exceedingly grateful. When intestinal 
perforation occurs, opium should be administered in addition to 
the indicated remedy, and in doses sufficient to secure absence 
of intestinal motion for several days. The hypogastrium must 
be examined by palpation and percussion twice daily, and the 
catheter used when necessary. In long protracted cases, bed- 
sores are to be prevented by frequent changes of position, by the 
removal of pressure by means of cold water bags or air cushions, 
and by bathing the parts with whisky and arnica. Points of 
pressure may also be protected by a piece of kid spread smoothly 
with soap plaster. When erosions appear, the parts should be 
washed with a weak solution of carbolic acid, and afterwards 
dressed with lint covered with the glycerole of calendula, or with 
equal parts of copaiba and castor oil. 

The cold bath, first recommended by James Currie, of Liver- 
pool, England, in 1797, but which had fallen into disuse, was re- 
vived by Brand in 1868, and is now quite extensively used in 
Europe. It has not, however, been very generally practiced in 
this country, and it is not probable that it will be accepted in 
the immediate future as a general method of treatment of typhoid 
fever. Mild cases do not require it, and in advanced cases it is 
not safe. It should never be used after the second week of the 
fever. And as a general rule, if after using from four to eight 
baths in the course of twenty-four hours, the fever rises to the 
same or a higher degree than before using the bath, little or no 
benefit will accrue from a continuance. 

Loomis gives the following general rules for using Ziemssen's 
gradual method of bathing: As soon as the axillary tempera- 
ture in the evening rises above 103° Eahr., place the patient in a 
water-bath having a temperature of 70° Fahr. or 80° Fahr., and 
gradually lower that temperature by the addition of cold water 
or ice, until the temperature of the patient begins to fall. It 
may be necessary to lower the temperature of the bath to 60° 
Eahr. before the temperature of the patient is affected; but the 
lowering of the body temperature must be accomplished by the 
lowering of the temperature of the bath, care being taken that 
the latter does not fall below 60° Eahr. When the temperature 
begins to fall, the thermometrical observations must be renewed 
every two or three minutes. While the baths are being; used, 



192 LECTURES ON EEVEES. 

the temperature must be taken by placing the thermometer in the 
rectum. If it falls rapidly — that is, two or three degrees in five or 
six minutes — as soon as the fall has reached 103° Fahr., remove 
your patient from the bath ; if it falls slowly, as soon as it reaches 
101° Fahr., he should be removed and immediately placed in 
bed. Never keep the patient in the bath until the temperature 
shall have reached the normal standard; for this may cause him 
to pass from a condition of fever into a state of collapse, as the 
temperature continues to fall for some time after his removal 
from the bath. "While in the bath, cold should be applied to the 
head by means of a sponge wet in cold water or by an ice bag. 

The cold pack is much less effective than the bath, as four 
packs are only equivalent to one cold bath. Frequent sponging 
of the body with equal parts of aromatic vinegar and tepid water, 
or with tepid whisky and water, will allay dryness and heat of 
the skin, and if done in the evening will promote sleep. 

The diet should be nutritious, liquid, and on account of the 
enfeeblement of the digestive and assimilative powers, easily 
digestible. It should be administered in small quantities and at 
short intervals. The best beverage is fresh water, which may be 
given often. Milk and water, koumyss or thin barley water are 
grateful drinks. Fruits should be prohibited; and solid food 
must not be given until the temperature has remained at the 
normal for at least three successive days. After the first week 
as much food should be given as can be properly digested, and 
when there is extreme prostration it should be administered 
every half hour or hour. 

Milk, which has been aptly defined as fluid flesh, bone and 
nerve, leads the list of fever foods. It is the best diet during 
the stage of catarrhal inflammation. It does not, however, agree 
with all cases, and must not be used in unlimited quantities, as 
it sometimes lies in curds in the stomach and bowels. In order 
to make it more digestible it may be reduced by dilution with one- 
half or one-third of lime water. The addition of two or 
three grains of pepsin and pancreatin to each cupful of food 
proves a valuable aid to digestion. Usually patients will take 
from four to six quarts of milk and lime water per day. Meat 
broths made of beef, mutton, veal or chicken, and containing a 
little barley or well cooked rice, may be given. The addition of 
claret or port serves to make the broths more palatable. Gen- 



DIETETIC TREATMENT. 193 

erally it will be well to alternate milk with the broths, every two 
hours during the clay, and every three hours during the night. 
Koumyss or fresh buttermilk often proves a very grateful 
change to patients who weary of milk, and may be given as a 
substitute where patients will not drink the latter. 

Beef -tea, which is claimed by some practitioners to be the 
proper diet for typhoid patients, will never take the place of 
milk. To prepare it,* chop a pound of lean beef into very small 
pieces, pour over it about a pint of cold water, cover, and let it 
stand two hours by the side of the fire; then place it on the 
fire and allow it to boil for a half hoar. Afterwards remove the 
scum, and skim off all the fat; salt to the taste; do not filter 
or strain it, simply pour it off. If rightly made it should have' 
a rich brown appearance when stirred. As a rule more patients 
dislike than like it. The place of usefulness assigned to it is 
after the middle of the second week, and yet I am free to say that 
you will be often disappointed in its use. When administered 
indiscriminately it is supposed to have a tendency to keep up the 
temperature. 

For general use you will find Leube's Beef Solutionf the best 
animal diet preparation, as it is highly nutritious and is more 
easily digested than any other of the meat extracts. When- 
ever the stomach fails to retain food and rejects even Leube's 
solution, Valentine's Meat Juice may be administered hypo- 
dermatically in doses of from one to two fluid drachms. Meat- 
pancreas injections, so useful in gastric ulcer, and prepared 
by adding one and one-half ounces of finely chopped pan- 
creas, and five ounces of finely scraped beef, to three ounces of 
lukewarm water, and stirring to the consistence of thick pulp, 
may if used with caution, per rectum, be of benefit in patients 
who are very low. In cases of extreme prostration the intrave- 
nous injection of milk — prepared by adding ten grains of car- 
bonate of ammonia to six ounces of goat's milk — has been used 
with good effect. 

Alcoholic stimulants are unnecessary and injurious up to the 
end of the second week, and many cases require no stimulation 

* Johnston's Fluid Beef, or Scott and Bowne's Soluble Peptonized Granu- 
lated Beef, may be used. 

t Prepared by Ph. Rudisch, of New York. 



194 LECTURES ON FEVERS. 

throughout the whole course of the attack. The indications 
which call for their administration are mainly such as are de- 
pendent upon the weakness of the heart's action, and consist of 
a feeble or imperceptible cardiac impulse, and a diminution or 
early subsidence of the first sound. Stimulation may be con- 
tinued, when, under its use, the tongue becomes moist, the first 
sound grows more distinct, the pulse slower, and the sound clear; 
it should be abandoned, when, under its administration, the 
tongue becomes dry, the heart's action becomes more rapid, or 
the brain symptoms deepen. It is difficult to lay down rules as 
to the quantity of wine or other stimulants to be exhibited; every 
case has its own peculiarities. At first half a wine-glassful of 
wine-whey — prepared by adding half a pint of sherry to one pint 
of boiling milk, and straining after coagulation — may be given 
every three hours. Later, if the patient grows weaker, half an 
ounce of brandy or an ounce of wine may be given with the 
same or twice as much milk, every two to four hours, especially 
at night. Whenever the urine becomes albuminous, brandy and 
whisky must be used with the greatest caution. Never despair 
as long as your patient can sivalloiv. 

During convalescence, if stimulants are needed, sherry wine 
either alone or as wine-whey is the most eligible. In the first 
week of convalescence, the diet should be restricted to milk cus- 
tards, and farinaceous foods and animal broths. Wine of pepsin 
taken after each meal materially aids digestion. After the end 
of a week, solid food may be gradually resumed. Milk punch 
and egg-nog are often of service. If diarrhea is present dur- 
ing convalescence it is safer to restrict the patient to milk and 
cream. All exercise other than simply walking around the 
iroom should be prohibited. 

When convalescence is tardy the patient will be greatly bene- 
fited by change of air and scenery. A short residence at the sea- 
shore usually exerts a very salutary influence in promoting an 
early restoration to health. Aitkin utters a truism when he 
says no man can be considered fit for work for three or four 
months after an attack of severe typhoid fever. 



LECTURE XIII. 

Yellow Fever. 

We are to-day to study Yellow Fever — the second in the list 
of miasmatic-contagions fevers. 

Definition. — It may be defined as a continued fever produced 
by the introduction into the human organism of a specific poison, 
and consisting of a single paroxysm of indefinite duration, but 
always tending to terminate in two or four days, or a multiple 
thereof. It is characterized by early epigastric tenderness, 
severe nausea, projectile vomiting; fiery eyes, violent supra-orbi- 
tal headache ; pains in the back and calves of the legs ; a slow, 
uncertain, easily compressed pulse; a deep yellow or bronzed 
skin — after the third day; black vomit — one or two days pre- 
vious to death; suppression of urine and albuminuria. It is a 
portable disease and has an average duration of six days. One 
attack affords almost certain immunity for a life-time. After 
death constant lesions of the liver, kidneys, blood, skin, and 
mucous membrane are found. 

Synonyms. — It has been variously described as: Febris flava. 
Febris typhus icterodes. Febris cum nigro vomito. Fievre 
jaune; and Typhus d'Amerique. 

History. — It is said to have made its first appearance either 
in the West Indies or in Mexico many years before the Spanish 
conquest. It prevailed in Central America in 1596, and among 
the Indians of New England as early as 1618. It visited New 
York for the first time in 1668, Charleston in 1682, Boston in 
1691, Philadelphia in 1695, and the Gulf Coast in 1702. It made 
its first appearance in Europe, at Cadiz, Spain, in 1705. Pensa- 
cola received its first visitation in 1764, and New Orleans in 1796. 

(195) 



196 LECTURES ON FEVEES. 

The epidemic of 1804, in Spain, was attended by the heaviest 
mortality on record. The worst epidemic in New Orleans was 
in 1853. Memphis was first visited in 1855, although the disease 
appeared at Ft. Pickering, now a suburb, in 1828. The second 
visitation was in 1867. A very destructive epidemic devastated 
the city in 1873, and in 1878 a little less than one-third of the 
total population died. In 1870 the disease was very destructive 
in Barcelona, Spain, and in 1871 at Buenos Ayres. In the great 
epidemic of 1878 the mortality record of New Orleans — which 
stands next to Memphis — is estimated at 4,600, and that of Vicks- 
burg at 872. In this epidemic the disease extended as far north 
as St. Louis, Mo., Cairo, 111., and Gallipolis, Ohio. 

Geographical Limits. — Yellow fever is uncommon in elevated 
regions, and seldom occurs beyond 4,000 feet above the level o£ 
the sea. It rarely prevails beyond 45° north latitude and 23° 
south latitude. Epidemics have occurred as far north as Quebec, 
Canada; as far south as Montevideo, Uruguay; as far east as. 
Madrid, Spain; and as far west as Mexico. The conspicuous 
zones for its ravages are: Barbadoes, West Indies, on the east; 
Tampico, Mexico, on the west; Bio de Janeiro, Brazil, on the 
south; and Charleston, U. S.. on the north. 

In Europe it has invaded Spain, Portugal, Italy, France and 
England. It has frequently prevailed along the western coast 
of Africa; recently in the province of Senegal. In South Amer- 
ica it has prevailed in Venezuela, Colombia, Peru, Bolivia, 
Buenos Ayres, and Brazil. In North America, it has invaded 
Mexico, the West Indies, Canada, and all the States of the 
Union, except Wisconsin, Michigan, Iowa, Minnesota, Kansas,, 
Nebraska, California Colorado, Oregon, Nevada, and the Terri- 
tories, omitting the Indian Territory. It often visits the tropi- 
cal islands of the Atlantic, but has never made its appearance 
among the islands of the Pacific. It is unknown in Asia, Aus- 
tralia, the East Indies, and along the eastern shores of Africa; 
and has only been felt sporadically along the Pacific coast of the 
American continent. 

Yellow fever has become naturalized in Brazil, the West In- 
dies, Venezuela, New Granada, Mexico, and along the Gulf and 
south Atlantic coasts of this country as far as Charleston. 

Etiology. — The nature and source of the yellow fever poison 



ETIOLOGY. 197 

•are as yet enshrouded in uncertainty. We simply know that it 
originates outside of the organism, that it can be reproduced 
only when the atmosphere has become loaded with emanations 
from animal and vegetable decomposition, that it is portable, and 
that it can be conveyed from one locality to another by means of 
clothing, merchandise, and more particularly in the holds of 
vessels. It resembles the poison of typhoid fever in that it can- 
not be conveyed directly from the sick to the healthy, but must 
first be deposited in, or come in contact with, decomposing organic 
matters. Atmospheric air is the usual medium through which 
the infection is received into the human system. 

As no satisfactory proof of the de novo origin of yellow fever 
can be found, many ingenious and at times absurd theories of 
causation have been promulgated by physicians. Dr. Stone 
holds to the wave or cycle theory, and believes that the epidemic 
influence is wafted through the atmosphere in waves or cycles, 
in gradual and regular approaches. Dr. Stille attributes its 
origin in this country to the Gulf Stream. Dr. Ford advocates 
the theory of fermentation. Dr. Labadie favors the explosive 
theory, believing that it is a peculiar subtle poison that explodes 
in the air, like an inflammable substance. But the majority of 
physicians hold with Dr. Davidson that it is due to a living or- 
ganized microscopicentity, which, generated out of pre-existing 
germs under favorable circumstances, propagates itself indef- 
initely ; and, as Sternberg suggests, that something given 
off from the body of the sick, after a time and with the concur- 
rence of favorable conditions, becomes or produces the true 
poison of the disease. 

The meteorological and local conditions which favor its evo- 
lution, and which seem to be necessary to the evolution of yel- 
low fever epidemics are: 

1. A continued high temperature. — Yellow fever never spreads 
where the thermometer stands less than 72° Fahr. The average 
temperature for twenty-four hours must be above 77° Fahr. 
Heat may be considered as the only essential in the causation of 
ihe disease. 

2. Excess of moisture. — A certain amount of moisture either 
in the atmosphere or in the substance of the soil is generally 
necessary for the reproduction of the germ. Heavy rains fol- 
lowed by a very high temperature favor the rapid spread of yellow 



198 LECTURES ON FEVERS. 

fever. A sufficient amount of moisture is, in this country, always 
present in the atmosphere. In the Southern States, the clear days 
of the season of the disease are called " yellow fever weather." 

3. Organic matters in a state of decomposition. — Decaying ani- 
mal and vegetable matters are exceedingly favorable if not essen- 
tial to the reproduction of the germ. Bilge-water in the holds 
of ships may be the medium of transportation of the morbific 
agent from port to port, while accumulated filth, especially 
city garbage, affords a rich nidus for its reproduction and dis- 
semination in crowded cities. 

4. Nearness to a tropical sea, or to a large river emptying into 
such sea. — Yellow fever is almost wholly confined to level dis- 
tricts in large river and sea-port cities of warm climates. The 
germ travels three times as fast in tropical regions as it does in 
the outer limits of the fever zone. Its average rate of progress 
is about forty feet per day. 

5. A deficiency of ozone in the atmosphere. 

The germs — (micrococci?) — of yellow fever being portable,, 
may be conveyed in baggage or merchandise (fomites) along 
the routes of travel from infected to non-infected districts. Un- 
less so conveyed, as their progress is naturally very slow, the in- 
fection may be confined to a single block or district of a city. 
(This fact alone must always render judicious quarantine of vital 
importance). They are commonly most active near the surface 
of the earth, and at night. They may be dormant for many years 
consecutively, only requiring a concurrence of causes to arouse 
them to disease producing activity. Few germs survive a tem- 
perature below 32° Fahr. and all perish at 212° Fahr. 

Epidemics of yellow fever are self -limited and seldom continue 
longer than from sixty to seventy days. They usually appear in 
this country in July or August and disappear upon the advent 
of frost. Malignant intermittent fevers frequently precede out- 
breaks of yellow fever epidemics. South and easterly winds 
favor the development of the disease, while north and west winds 
tend to arrest it. Negroes are most exempt from its attacks. 
Having had the disease is a partial protection against a recur- 
rence. A prolonged residence in a yellow fever district also 
renders the individual less susceptible. This diminished sus- 
ceptibility will, however, last only while the individual remains 



ETIOLOGY. 199 

constantly in the yellow fever region. And acclimation is never 
complete until the disease has been experienced. Cooks, bakers 
and blacksmiths, and such as work over fire are specially predis- 
posed to yellow fever, while scavengers, tanners and butchers, 
are from their occupation, afforded partial immunity. In some 
epidemics domestic animals have sickened and died from the 
infection. 

Touching the question of contagion or non-contagion, which 
has given rise to much bitter discussion, I must say to you, that 
the weight of opinion and of evidence is decidedly against the 
theory of personal contagion. Dr. Lawson writes, it is worthy 
of observation that the great majority of the members of the pro- 
fession who have resided some years in the tropics and had con- 
stant experience of yellow fever, entertain the opinion of non- 
contagion, and it is only among those who have met the disease 
occasionally, or who have never been brought in contact with it, 
that the idea of contagion is generally received. 

In summing up the etiology of yellow fever we arrive legiti- 
mately at the following conclusions: 

1. The disease is produced by a specific germ. 

2. The impression on the organism is as specific as that pro- 
duced by typhoid fever. 

3. An attack affords partial protection from subsequent 
attacks. 

4. The white population of sanguine temperament suffer most 
severely, while the blacks are partially exempt. 

5. The germs have the power of self -reproduction outside the 
body, under favorable local and meteorological conditions. 

6. A temperature below 72° Fahr. is unfavorable to the propa- 
gation of germs. 

7. The disease is not personally contagious, because of the 
immature state of the germinal principle contained in the exha- 
lations and discharges of the sick. 

8. The germs may be conveyed from infected to non-infected 
districts by fomites. 

9. The period of incubation of the germ is from two to nine 
days. 

10. The average length of an epidemic is from sixty to seventy 
days. 



200 LECTURES ON FEVEES. 

Clinical History. — The clinical history embraces a descrip- 
tion of the prodromal stage, the stage of initial fever or the 
paroxysm proper, and the period of sequels which includes the 
stages of calm and of reactionary fever. 

The period of incubaiion of yellow fever — the time which 
elapses between the absorption of the poison by the organism, 
and the appearance of the first signs of the disease — varies from 
a few hours to several days or even weeks. Its average length 
is from one to two or three days. Prodromal phenomena simi- 
lar to those observed in other infectious diseases, and consisting 
of a general feeling of uneasiness or discomfort, headache, pains 
in the limbs, and loss of appetite, occasionally precede the attack. 
Usually, however, the onset is apparently abrupt, the disease 
taking the patient by surprise, either in the morning, while en- 
gaged in business, or during sleep. 

The paroxysm. — In most cases the ushering in symptom, 
which marks the beginning of the stage of initial fever, is a chilly 
feeling along the spine passing into actual rigor. Immediately 
the patient feels seriously ill, complains of stinging pains in the 
forehead and temples, as also of pains in the back and limbs, and 
more especially in the calves of the legs. Soon the sensation of 
cold alternates with, and rapidly gives way to one of heat. The 
patient becomes restless, and presents an appearance of alarm 
and anxiety. The countenance is flushed, the conjunctiva in- 
tensely congested, and the eye has a peculiar muddy appearance. 
The tongue is covered by a white or thin yellowish fur, and is 
scarlet colored at the tip and edges. The fauces appear bright 
red and cedematous. The skin becomes hot, and is either dry or 
bathed in profuse perspiration. Frequently, as early as the 
second day it emits a peculiar cadaveric odor. The temperature 
rises rapidly and often reaches 102° Fahr. or 104° Fahr. within 
a few hours after the chill. The respiration is hurried and fre- 
quently irregular. The pulse is full and hard, averaging from 
one hundred to one hundred and ten beats per minute. The 
epigastrium is extremely sensitive to pressure, and occasionally 
there is nausea with frequent and unsuccessful attempts at 
vomiting. The bowels are usually constipated; if discharges 
occur they are dark colored and offensive. On the second day, 
in those exceptional cases which assume the ephemeral form. 
after some free alvine or urinary evacuations, the pulse and tern- 



CLINICAL HISTORY. 201 

perature may suddenly fall, the fever speedily subside, and the 
patient enter upon a rapid convalescence. Such a course is, how- 
ever, by no means common, for in the majority of instances the 
febrile movement continues to the third or fourth day. The 
temperature then usually reaches its maximum height on the 
evening of the second, which in this country rarely exceeds 104° 
Fahr. In rare cases the thermometer has been known to regis- 
ter 105° Fahr. or even 107° Fahr. The pulse generally falls 
after the second day, with a progressively increasing rapidity, 
and on the fourth day oscillates toward eighty. The mind is 
usually clear, but occasionally delirium makes its appearance on 
the second day. In mild cases this delirium may be confined to 
irrational utterances, while in severe cases it may become so vio- 
lent as to render physical restraint necessary. In fatal cases 
delirium is rarely absent. Usually on the morning of the third 
day, but frequently not before the fourth or fifth day, the febrile 
storm commences to subside. After some free evacuation of the 
bowels or bladder, the temperature begins to fall, and the pulse 
continues its steady downward course begun on the second day. 
All the symptoms abate except the epigastric tenderness. The 
patient sits up and feels better ; and in favorable cases convales- 
cence now commences. 

The stage of calm. — Much more often the defervescence is not 
complete, the temperature does not fall below 100° Fahr. and the 
patient has simply passed into that deceptive first period of se- 
quels — the stage of calm. The duration of this so-called second 
stage is very short, rarely exceeding from two to three or at the 
utmost twenty-four hours. Graver symptoms of a typhoid char- 
acter now appear, and the patient approaches the third stage of 
the disease, — the second sequel — the stage of reactionary fever. 

The stage of reactionary fever. — The temperature which had 
commenced to fall rises again rapidly, and after two days reaches 
104° Fahr. The pulse becomes quick, at times slow, but always 
small and thready. The stomach becomes more irritable, and 
rejects all food and drink. The conjunctiva presents a yellow- 
ish appearance — sometimes even as early as the third day. The 
skin, in about one-sixth of the cases, assumes an icteroid hue, 
which is especially marked about the face, neck and shoulders. 
The tongue is dry and covered with a dirty brownish fur; the 
gums are of a purplish color. The nervous restlessness and the 



202 LECTUBES ON FEVERS. 

delirium return, or else the patient lies in a state of complete 
apathy and unconcern. Frequently muscular spasms and sub- 
sultus tendinum occur. The urine is scanty, of a sulphur or 
saffron yellow color, and contains — after the fifth day — granular 
tube casts. The distress and burning in the epigastrium become 
more and more severe. As the vomiting continues, flakes of 
black hemorrhagic matter mixed with a thin mucoid fluid, and 
known as black vomit are ejected. The vomiting now is some- 
what peculiar in that it is projectile in character. It may occur 
on the second or third day of the fever, but more commonly it 
does not come on until thirty-six or forty-eight hours before 
death. The ejection of the black vomit, though prostrating to 
the patient, often relieves the sensation of pressure or tightness 
over the epigastrium. 

Black vomit. — When allowed to stand, black vomit separates 
into a thin mucoid fluid and a solid substance resembling coffee- 
grounds. The mucoid fluid is made up mainly of water mixed 
with the mucous secretion of the stomach. The solid matters of 
the vomit consist of colorless blood globules, epithelium, disin- 
tegrated matters of food, and free haemoglobin or heematin in the 
form of yellow amorphous patches. Frequently zooglcea of mi- 
crococcus are observed in fresh specimens. And very often speci- 
mens of the yeast plant or cryptococcus cerevisiae are found. 

If the disease is to take a favorable turn, usually after a con- 
tinuance of twelve hours, amid profuse sweats all the symptoms 
abate, and the fever gradually subsides. The pulse falls again, 
sometimes as low as forty per minute; and the temperature 
slowly returns to the normal. The skin becomes moist, and the 
discoloration fades. The gastric symptoms become greatly di- 
minished; and the delirium disappears. Excessive nervous 
prostration now remains as the most prominent symptom. As 
a rule convalescence is tardy, being frequently protracted by 
such complications as diarrhea, visceral congestions, abscesses, 
periostitis of the tibia, suppurative parotitis, etc. 

In cases which are to terminate fatally, there is no ameliora- 
tion, the symptoms becoming more and more grave as the disease 
progresses. The temperature steadily rises, while the pulse fre- 
quently sinks. The tongue is hard, dry and covered with a brown 
or blackish fur. The black vomit increases ; and frequent hem- 
orrhages take place from the nose, mouth, kidneys and bowels. 



ANALYSIS OF CHART. 203 

The -urine becomes very scanty, albuminous, and at times sup- 
pressed. The countenance is sunken, and the face is of a dusky 
color. The delirium may be either low muttering or active until 
near the close of life. In severe cases hiccough, clammy sweats, 
convulsions, and involuntary evacuations precede dissolution. 
Death most frequently takes place on the fourth, fifth or sixth 
day. Some epidemics are much more fatal than others. The 
ratio of mortality is much less during the latter part than dur- 
ing the early part of an epidemic. 

Duration. — The average duration of yellow fever is less than 
one week. 

ANALYSIS OF CHART. 

The Cutaneous Surface. — The yellow color of the skin from 
which the disease receives its name — yellow fever — is reported 
as being present in not more than one case in six. It seldom 
appears before the third day. It is first noticed about the eyes 
whence it gradually extends downwards over the whole body. 
The icteroid hue is caused by the staining of the tissues with 
pigment matter formed from the loematin during the degenera- 
tive changes produced by the action of the yellow fever poison 
upon the red globules of the blood . This discoloration, there- 
fore, is a real hsematogenous jaundice, and is not due, as some 
suppose, to a retention and absorption of the bile. 

The perspiration becomes especially marked after the first 
twenty-four hours. In some cases the sweat is so profuse, as to 
wet, not only the clothing, but also the bedding upon which the 
patient rests. Along with the sweat, a peculiar, somewhat cadav- 
erous odor is perceived to emanate from the skin and in the 
breath. Frequently a burning, stinging sensation is imparted 
to the tips of the fingers, when the moist and feverish skin is 
touched. In severe cases the face is of a dusky hue, though the 
skin generally is of an orange-yellow color. 

The Digestive Tract. — The tongue is early covered by a 
white cream-like film, except at the tip and edges, which are of 
a bright scarlet tint. Later it assumes a yellow or brownish 
tint, and the edges if clean are of a purplish color. In fatal 
cases towards the close of life it becomes hard, dry, and covered 
with a brown or blackish fur. There is loss of appetite with 
nausea and a constant, often unsuccessful, attempt to vomit from 



204 



LECTURES ON EEVERS. 

CHART IX.— Yellow Fever 





Non-contagious. Endemic or Epidemic. Portable. 




Incubation. 


Twelve hours to five days. 




Pei-iods : 


The paroxysm. 


The period of sequels. 




Stages : 


Stage of initial fevei 


Stage of calm. 


Stage of 
reactionary lever. 




Duration: 


One to three or four 

days. 


Twelve hours to two 
days. 


Twelve to forty-eight 
hours. 




Temperature: 


104° on second day, 


100° Fahr. or normal. 


10f° Fahr. 




Pulse: 


90 to 120, (gaseous.) 


Approaches the nor- 
mal. 


90 to 120. 
Thread-like. 




Skin: 


Yellow on third day. 
Cadaveric odor.' 


Discoloration sub- 
sides. 


Orange-yellow color. 
Profuse sweats pre- 
cede convalescence. 




Eyes : 


Muddy at first, after- 
wards suffused. 
Resemble balls of fire. 


Subsidence of 
symptoms. 


Red and watery. 




Extremities: 


Pain in the back and 
calves. 


Muscular prostration. 
Pain in back and legs 




Head: 


Supra-orbital 
headache. 


Slight cephalalgia. 


Apathy, delirium or 
stupor. 




Tongue : 


White coat. Red 
edges. 


White coating. 


Dry, brown, cracked. 




Stomach : 


Nausea. Projectile 

vomiting. Yellow or 

g'reenish. 


Epigastric tender- 
ness. 


Projectile vomiting. 

Black vomit. 

Hiccough. 




Bowels : 


Constipated. 


Constipated, 


At times, hemorrhage 




Urine: 


Saffron colored, sup- 
pressed. 


Increased flow. 


Suppressed. Album- 
inuria. 




Blood: 


Serrated globules. Diminution of fibrin. Uraemia. 




Kidneys: 


Parenchymatous nephritis. 




Liver: 


Slightly enlarged. Fatty degeneration. 




Nervous system: 


Inflammation of lumbar arachnoid, and of neurolemma of ganglia 
of hepatic and coeliac plexuses. 




Duration: 


Average of disease, 6 days. Average of epidemic, 60 to 70 days 




Prognosis: 


Mortality varies from 5 to To per cent. Most fatal in children. 



ANALYSIS OF CHAET. 205 

the onset of the disease. And generally there is a sensation of 
dull aching pain or pressure in the epigastrium. Thirst for cold 
drinks is a prominent symptom. 

Vomiting comes on soon after the initial chill, and continues 
throughout the course of the fever. At first the vomited matters 
consist of a thin mucoid fluid, of a white and frothy appearance, 
frequently mixed with bile. Later — usually in the third stage — ■ 
the mucoid fluid becomes mixed with flakes of black hemorrha- 
gic matter, or even with pure blood. As the vomiting continues, 
the flakes of black hemorrhagic matter gradually increase in 
amount, until finally a quantity of them mixed with thin mucoid 
fluid — and styled the black vomit — is thrown up forcibly, and at 
once. This peculiar vomit, which is brownish-black in appear- 
ance, is an almost pathognomonic sign of the disease, and may 
vary in quantity from a mere stain, to many pints in twenty-four 
hours. It may occur as early as the second or third day, but 
usually it does not set in until thirty-six or forty-eight hours be- 
fore death . Statistics show that it is present in not more than 
thirty-three per cent of all dying cases. When present it should 
always be regarded as a grave symptom. Children are more 
apt to recover after it has occurred, than are grown people. In 
some cases, black matters resembling black vomit are passed 
from the bowels, which, otherwise, are constipated. In many 
instances hiccough appears as the patient approaches collapse. 
Critical alvme evacuations frequently precede an abatement of 
febrile symptoms. 

The Urine. — Early in the fever the urine has a reddish tint 
and displays an acid reaction. After the second day it almost in- 
variably contains albumen. Granular tube casts may be dis- 
covered on the fifth day. Albumen is found in all fatal cases. 
In severe cases the urine becomes very scanty, contains a mini- 
mum of urea, and may be suppressed from twelve to forty-eight 
hours. Suppression of urine usually occurs during the latter 
part of the third stage, and is one of the most dangerous symp- 
toms. When complete it is more unfavorable than the black 
vomit, as death may speedily ensue from uraemia. Biliary pig- 
ment appearing towards the close of the disease is generally con- 
sidered a favorable symptom. 

The Eyes.— At the onset the eyes present a muddy appear- 
ance owing to slight cedematous swelling of the conjunctiva.. 



206 



LECTURES ON FEVERS. 



Later, from increased conjunctival congestion, they become moist, 
and resemble balls of fire. 

The Temperature. — The characteristic symptom as regards 
temperature in yellow fever is, that the highest point is reached 
at the outset of the disease. In mild cases the maximum is 
reached within a few hours after the initial chill, while in pro- 
tracted cases it is seldom delayed beyond the second or third 
day. Fig. 13 (p. 207.) represents the temperature curve in typ- 
ical cases of two, four, and eight days duration, 

During the paroxysm the average height reached in the axilla 
is 104° Fahr. In exceptional cases it may mount to 106° Fahr, 
or higher. In the stage of calm it falls to 100 Fahr., but rises 
again to 104° Fahr . or even higher as the patient enters the third 
stage. After remaining stationary for from twelve to forty-eight 
hours, it falls to the normal standard, where it remains until con- 
valescence is fully established. A considerable rise in tempera- 
ture frequently occurs, shortly before death, in fatal cases. 

The following table arranged by Sternberg, shows the prog- 
nostic value of temperature observations in yellow fever. 



Cases having 
temperature of 1 


No. of Cases. 


No. of Deaths. 


Percentage of Deaths 
to Cases. 


107° and above 


13 


13 


100 


From 106° to 107° 


9 


9 


100 


105° — 106° 


36 


22 


61 


104° — 105° 


80 


24 


30 


103° — 104° 


87 


6 




102° — 103° 


29 







101° — 102° 


15 





— 


Total 


269 


74 


| 27-5 



The Pulse. — The pulse is most rapid at the outset of the 
fever. Its maximum average — 120 beats — is reached on the 
first day. Immediately afterwards it begins to fall at about the 
rate of ten beats every twenty-four hours. This steady decline, 
which begins as early as the second day, when taken in connec- 
tion with the rise in temperature, is, I would have you remem- 
ber, one of the most reliable guides in the differential diagnosis 
of this disease. 

The Nervous System. — Slight headache occurs among the 
early prodromes. Then comes the chill or rigor, followed by 
general symptoms of hyperemia of the cerebro-spinal axis, and 



TEMPERATURE RANGE. 



20V 



Fig. 13. 



Day 


1 





3 


4 


5 


G 


7 


s 


9 


10 


ii 


12 


13 


14 


15 


105 






























104 
































103 












2 


Days 
















102 
































101 
































100 






V 


























99 






V 


v- 


A 




/A 


•* 


V^ 


VI 


V 










9S 












































































105 


_ 






























101 
































103 








\ 




4 


Day 


3 
















102 








\ 
























101 










\ 














/ 








100 










\ 








/ 


V\ 






\ < 


/ 


i 


99 












1 






y 


\ 






1/ 


V 


V 


98 












U 


>/ 


'S/ 1 














v\ 












r 




i 


i 






105 c 
































101 
































103 


A 


V 








8 


Day 


5 
















102 






\ 


























101 














A 


\ 
















100 
















"\ 












/ 


\ 


99 
















1 


\ 


A 


^*> 


/ 


v 


M 


V 


93 




— 














u 


y 


^ 


V 


/ 







Temperature Range in typical cases of Yellow Fever, of two, four, and 
eight days duration Rafter Sternberg.) 



208 LECTUBES ON FEVERS. 

of the sympathetic ganglia of the abdomen and thorax. Mild de- 
lirium frequently occurs as early as the second day. In many cases 
the delirium becomes wild in character, and is marked by a con- 
stant desire on the part of the patient to escape. In cases which 
terminate fatally the delirium usually remains active till death 
approaches. In the " apoplectic grade " the patients are struck 
down suddenly, become perfectly comatose, hemorrhages take 
place, and death speedily ensues. The fatality in most instances 
is almost always dependent upon hyperemia of the brain. In 
cases that recover, excessive nervous prostration, and the general 
feebleness of the organism render convalescence tardy and oft- 
times discouraging. 

Morbid Anatomy. — The anatomical changes which occur in 
yellow fever resemble in many respects those of the miasmatic 
and contagious fevers. 

The Liver. — The liver is the seat of the most constant and 
characteristic lesion of the disease. The typical pathological 
change is one of fatty infiltration, and may involve the whole 
gland, or be confined to one lobe or to a small portion of a lobe. 
On section the organ presents a peculiar pale yellow, greenish or 
blackish-brown appearance. Viewed under the microscope the 
hepatic cells are observed to be more or less filled with oil 
globules. Sometimes the pathological changes advance to a true 
fatty degeneration of the protoplasm of the hepatic cells. In 
such cases the entire liver cells will appear filled with large fat 
globules; presenting the condition known as acute fatty degen- 
eration. Very frequently, especially in drunkards, cirrhosis is 
associated with fatty degeneration. 

The Kidneys. — The kidneys are always more or less congested 
and enlarged, and their pelves are frequently the seat of catarrhal 
inflammation. In the majority of fatal cases, the leading patho- 
logical change consists in a degeneration of the epithelium lin- 
ing the uriniferous tubules. As a result of the degeneration, 
numerous so-called albuminous cylinders are formed in the in- 
terior of the tubules. The largest of these cylinders are formed 
in the convoluted portions — the tubuli contorti — and in the in- 
termediate canals. During the metamorphosis larger fat glob- 
ules are rarely observed. 

The suppression of urine which appears in some cases is prob- 



MORBID ANATOMY. 209 

ably due to general atrophy and degeneration of the renal epithe- 
lium. 

The Heart. — In nncomplicated cases the heart is generally 
found normal in size and form, empty, and firmly contracted. 
At times it is pale, soft and flabby, and presents changes similar 
to those found in typhoid fever. The pericardium often con- 
tains from one to two ounces of yellow or reddish serum. 
Partially organized yellowish coagula, resulting from the 
slowing of the circulation from the feebleness of heart power, 
are occasionally found in the cavities of the heart. 

The Blood, — The fibrin of the blood is diminished in quantity. 
The colored corpuscles undergo changes which indicate loss of 
vitality. The white corpuscles are reduced in number, and con- 
tain an unusual quantity of fat granules. 

When removed from the body, the blood of yellow fever rapidly 
undergoes ammoniacal changes. 

The Brain, — The nervous system is always seriously impli- 
cated. The pia mater is almost invariably found in a state of 
hyperemia. The arachnoid is frequently found not only opaque 
but thickened. The brain is congested throughout its whole 
substance, but more especially in the parietal lobes. The general 
cerebral hyperemia depends upon a depression of the vaso-motor 
nerves, followed by a relaxation of the arterial walls. 

Cadaveric rigidity appears early and is strongly marked. 

The Stomach. — In almost all cases the mucous membrane of the 
stomach is found more or less congested. The congestion is con- 
fined to smaller or larger spots, and appears mostly along the 
greater curvature. In fatal cases, small red spots or patches, re- 
sembling small ecchymoses or extravasations of blood are found. 

The Skin. — The intensity of the color of the skin varies usu- 
ally in proportion to the severity of the case. It is of an orange- 
yellow color, and is deepest about the head and trunk, fading 
towards the feet. Frequently, approaching the end of an epi- 
demic, the discoloration extends only to or slightly below the 
knees. 

In most instances the almost characteristic yellow tint is ob- 
served in all the tissues of the body. 



LECTUEE XIV. 

Yellow Fey er.— (Continued.) 

In the lecture immediately preceding I gave you the main 
points in the clinical history and morbid anatomy of yellow 
fever ; I will now state, as fully as the limits of the hour will 
permit, what is at present known concerning its differential 
diagnosis and treatment. 

Differential Diagnosis. — It is almost impossible to make an 
infallible diagnosis of yellow fever at the outset of the disease, 
as a number of other infectious maladies approach in a similar 
manner, and are attended by the same phenomena. On and after 
the second day, however, the recognition is generally easy. The 
falling of the pulse on the second day, with a simultaneous rise 
of the temperature of the body; the pain in the head, back, and 
calves of the legs; the suffused and watery eye; the presence of 
albumen in the urine on the third day; the epigastric tender- 
ness; the projectile vomiting; the orange-yellow color of the skin; 
the black vomit; and the short duration of the febrile phenomena, 
constitute a group of symptoms which are unmistakable. While 
fatty infiltration of the liver, along with the peculiar spotted con- 
gestion of the stomach, and the black vomit, are pathognomonic 
autopsic phenomena of the disease. 

Yellow fever may be confounded with remittent fever, relaps- 
ing fever, and acute yellow atrophy of the liver. 

Remittent fever is a disease of several paroxysms, prevails in 
inland towns, and is not portable. Yellow fever is a disease of 
one paroxysm, prevails in seaports, and is portable. The vomit- 
ing is projectile in character in yellow fever; it is non-projectile 

(210.) 



PROGNOSIS. 211 

In remittent fever. In yellow fever the pnlse after the second 
day falls while the temperature rises; in remittent fever it 
rises and falls with the fever heat. The yellow discoloration of 
the skin appears earlier and is more intense in yellow fever than 
in remittent fever. The urine is generally albuminous in yellow 
fever, rarely so in remittent fever. The spleen is but slightly 
or not at all affected in the former, while it is invariably en- 
larged in the latter. Black pigment granules (Fig. 9), which 
are found in the blood in remittent fever, are not seen in yellow 
fever. One attack of yellow fever affords almost certain immu- 
nity, while one of remittent rather predisposes to others. Au- 
topsies show a yellow, fatty liver in yellow fever, and a non- 
fatty bronzed liver in remittent fever. 

Relapsing or spirillum fever is contagious. Yellow fever is 
non-contagious. The discoloration of the skin in relapsing fever 
seldom appears before the relapse, while in yellow fever it fre- 
quently appears about the third day. Spirilla are found in the 
blood of the former, but not in that of the latter. The spleen 
which usually remains unaltered in yellow fever is as a rule en- 
larged in relapsing fever. 

Acute yellow atrophy of the liver may be differentiated from 
yellow fever by its history and by the steady diminution in size 
of the organ. 

Prognosis. — The prognosis is much more favorable under 
homoeopathic than under old school treatment; as under the for- 
mer the mortality is from five to tiuelve per cent; while under 
the latter it ranges from fifteen to seventy-five per cent. It varies 
greatly in different epidemics, and at different periods of the same 
epidemic. It is favorable when the febrile paroxysm is long and 
moderate, and when the albuminous urine does not contain casts. 
It should be guarded in new comers, and when the temperature 
runs high, the stomach is irritable, or the urine becomes scanty 
and contains albumen and casts. It is always grave when black 
vomit and urinary suppression supervene. According to statis- 
tics recovery is more frequent after the occurrence of black 
vomit, than after suppression of urine. Coma and convulsions 
are usually fatal symptoms dependent on uraemia. 

Treatment. — Prophylaxis. — In the prevention of yellow fever 
your attention must be directed in the first place to the inter- 
ception of its new importation, and in the second place to the 



212 LECTURES ON FEVERS. 

thwarting of its spreading after it lias once made its appearance^ 
A properly regulated and executed system of quarantine will — 
as far as is possible — prevent the early introduction of the spe- 
cific poison. And further, local hygiene and the best sanitary 
measures, are of almost equal importance with quarantine in 
checking the spread of imported yellow fever, and are of abso- 
lute necessity in the prevention of that of domestic origin. For 
importation of the morbific agent is not always necessary, as 
germs may be perpetuated, from epidemics of previous years, 
through the winter months, to break forth as soon as the intense 
heats of summer come to recuperate them, and enable them to 
develop and multiply. 

The question of yellow fever quarantine is a very vexed one. 
And as many of the best physicians entertain entirely different 
views, it will be of little use to discuss the matter here. Suffice 
it to say that most exhaustive papers on the subject are contained 
in the Report of the Bureau of Sanitary Science to the American 
Institute of Homoeopathy at its thirty-third session, in 1880. 

All vessels arriving from yellow fever ports, during summer 
months, near ports liable to it, should be inspected, and undergo 
thorough cleansing and disinfection. If found to be infected, 
such vessel or vessels should be quarantined until a thorough 
disinfection of the clothes and effects of sailors and passengers,, 
together with the cabins and general hold of the ship or ships 
has been obtained. ( Personal detention, other than of those ill> 
is seldom necessary. ) The clothes of passengers may be readily 
disinfected by dry heat, as most germs of disease become in- 
noxious with a temperature of 212° Fahr. The deck and wood- 
work should be washed in carbolized water, and the ship thor- 
oughly disinfected with either chlorine or sulphur dioxide. The 
space to be disinfected must be kept saturated with the gas for 
not less than one hour. 

As yellow fever usually proceeds along the highways of travel* 
cities and towns located within the fever zone, should quarantine 
against infected districts. Non-infected wards of a city or town 
should also institute quarantine regulations against infected ones, 
as the immediate limits of the disease may mostly be measured 
by fractions of a square mile. Camps of refuge should, when 
possible, be provided at convenient distances — say five or ten 
miles — from the city or town infected. Every sporadic case o£ 



PRINCIPAL REMEDIES. 213 

yellow fever occurring in cities should be sent at once to the 
quarantine hospital for treatment. 

In the midst of an epidemic, depopulation of rooms and avoid- 
ance of confined areas of stagnant air, afford the safest personal 
prophylaxis. People should live in the open air. The city 
should be kept in the best sanitary condition, and no animal 
matter should be allowed to decay within its limits. Personal 
contact with any one after the fever rises, and until it ceases, 
should be avoided. Cimicifuga and crotalus are recommended as 
preventives. In the sick room free ventilation, cleanliness, and 
other sanitary measures are of the utmost importance. All ex- 
creta and vomited matters should be placed in earthen vessels 
and thoroughly disinfected — without delay — before being thrown 
out. Piatt's chlorides should be sprinkled around the room and 
on the bed-clothing. All the bedding, together with the bed and 
body linen should be burned as soon as the patient is in conva- 
lescence. AVoolen articles may be disinfected by heat at a tem- 
perature slightly above 212° Fahr. All other articles that will 
stand boiling and washing with carbolized water and soap, should 
undergo the process. After the patient has either recovered or 
died, the room should be well and completely ventilated, disin- 
fected with sulphur dioxide, 01 frozen out — and this must be for 
at least seven consecutive days. The floors and wood- work of 
the apartment should be washed, and the walls whitewashed, or 
if already papered, thoroughly disinfected. That method of 
aerial disinfection which as formerly practiced, simply consists 
in making the air of a room smell strongly of carbolic acid, by 
.scattering carbolic powder on the floor, or of chlorine by placing 
a saucer of chloride of lime in one corner of the apartment, is a 
delusion, and as far as the destruction of specific germs is con- 
cerned is perfectly useless. 

No one should, after leaving, return to an infected district, 
until at least four weeks after the last case, or after a seven days* 
freeze. 

Principal Remedies. — The most important remedies during 
the cold period of the first stage are: Tinct of camphor, and 
veratrum alb. As soon as a reaction appears, and, in general 
terms, during the first twenty-four hours thereafter, aconite is 
indicated. During the second twenty-four, belladonna is usually 
the remedy, and during the third, bryonia. Veratrum viriole is 



214 LECTURES ON FEVERS. 

occasionally of service. Gelsemium and eupatoriun perf vie 
with the foregoing remedies in the stage of initial fever, espe- 
cially if malarial complications exist. Quinine may also prove 
of service in such cases, particularly when prostration begins to 
appear, and when in consequence of malarial influences fatal 
congestions threaten. It should be administered hypodermatic- 
ally and in appreciable doses, as suggested in a former lecture 
on Pernicious Fever (p. 99). 

Arsenicum alb. will be your main reliance in the stage of 
calm, although possibly if malarial influences predominate ' it 
may give way to either cinchona or natrum muricdicum. 

During the stage of reactionary fever, arsenicum is the rem- 
edy, par excellence. After it comes lachesis or possibly crotalus- 
In typhoid states either rhus tox. or arnica may be indicated. 
And in collapse you will need either arsenicum, crotalus, carbo 
veg., or hydrocyanic acid. Calcarea carb., or cinchona may 
prove serviceable during convalescence. 

As intercurrent remedies, you will think of: — 

Bell., caffeine, hyosc. or potassium bromide (per rectum), for 
the insomnia and nervous agitation. Ipecac for obstinate vom- 
iting in the first stage, and sidpho-carbolaie of soda, in from two 
to five-grain doses when it occurs in the last stage. Verat. alb. 
for vomiting with abdominal pain and great prostration. Tar- 
tar emet. when there is prolonged and distressing nausea in the 
third stage. Argentum nit, arsenicum, or cadmium sulphaie 
for the black vomit. Mercurius or colocynih, when either diar- 
rhea or dysentery supervene. Millefolium or gcdlic acid for 
hemorrhage from the mouth and gums. Argent, nit., ars. alb., 
crotalus, sulphuric acid or phos. for hemorrhage from the intes- 
tinal canal. Lycopodium, terebinthina or erigeron for hemor- 
rhage from the kidneys or bladder. Sabina for either uterine 
hemorrhage or threatened abortion. Euonymin, helonin, mere, 
cor., or cuprum, for albuminuria. Opium or hyosc. for urinary 
retention. Cantharis or apis for difficult urination, with scanty 
discharge, and cucumis citrullus — a decoction of watermelon 
seeds — in urinary suppression when other remedies fail. 

Leading" Indications. — The following are the guiding symp- 
toms for the different remedies: — 

Aconite. — Excessive restlessness and anxiety. Great timidity; 
fear of approaching death, Yertigo on rising. Burning head- 



LEADING INDICATIONS. 215 

ache. Pain in the forehead and temples. Face dark red; on 
rising turns deadly pale. Eyes injected and sensitive to light. 
Great sensitiveness to every noise. Epistaxis. Dryness of the 
mouth and lips. Thirst for large quantities of water. Burning 
and numbness in the throat. Nausea, vomiting and painful hic- 
cough. Heat and tenderness of the epigastrium. Pain in the 
back and extremities. Painful, anxious urging to urinate. Great 
weariness and loss of strength. 

Apis mel. — Absent mindedness and indifference. Headache^ 
pain in the forehead and temples relieved by pressure. Keel, 
hot, swollen face. Dryness of the tongue, scalding in the mouth 
and throat. Dysphagia. Suppression of urine. Strangury, or 
else urine scanty and high colored. Great desire to sleep. 

Argentum nit. — Headache, with boring in left frontal emi- 
nence, relieved by pressure. Intolerance of light. Conjunctiva 
pink or scarlet-red. Yellow, dirty-looking face. Tender, easily 
bleeding gums. Throat dark red. Black vomit. Tremulous 
weakness. Convulsions preceded by great restlessness. Sense 
of expansion of the body, particularly of the face and head. 

Arsenicum alb. — Great restlessness and anxiety, especially at 
night. Dread of death. Delirium with desire to escape. In- 
tense, dull or throbbing pain in the head. Excessive photopho- 
bia. Yellowness of the conjunctiva. Dark rings around the 
eyes. Yellow or livid face. Dry, brown or black tongue. Vio- 
lent thirst; drinks little but often. Yomiting, especially after 
drinking. Great anxiety in the epigastrium. Black vomit. Vio- 
lent burning pains in the abdomen with intolerable anguish. 
Black, putrid, bloody stools. Suppression or retention of urine. 
Involuntary urination. Bloody urine. Oppression of the chest 
with short, anxious breathing. Irregular, small, scarcely per- 
ceptible pulse. Bruised pain in the small of the back. Drawing 
pains in the legs. Sudden sinking of strength. Coldness of 
the body, with internal burning heat. Cold, clammy sweat. 

Baptisia. — General indisposition. Confusion of mind. Fron- 
tal headache with pressure. Lameness and soreness of eyeballs 
on moving. Dark, red, besotted expression. Dryness of the 
mouth and tongue. Foetid breath; difficult deglutition. Dark 
red scanty urine. Severe aching pain in the back and hips. 



216 LECTURES ON EEVERS. 

Tired, bruised, sick feeling all over. Delirious stupor. Symp- 
toms worse from evening until midnight. 

Belladonna. — Great anxiety and restlessness, with, desire to 
escape. Yertigo on turning over in bed. Nervous excitement 
with delirium. Cephalalgia with throbbing of the carotids. 
Pain relieved by pressing strongly on the forehead. Red, swol- 
len, staring eyes ; intolerance of light ; dilated or oscillating pu- 
pils. Eed halo around the light. Bright red, swollen face. 
Dryness of the mouth, tongue and throat. Burning and throb- 
bing in the stomach, with excessive thirst for cold water. Re- 
tention of urine. Menses too early and too profuse. Dry, 
burning heat with changing pulse. Pain in the back, loins and 
extremities. Intense burning heat within and without. In 
plethoric individuals. 

Bryonia. — Irritable mental state. Sensation as if sinking 
deep down in bed. Headache from the occiput down to the neck 
and shoulders, as if head would split, worse from motion. Pain, 
especially in the left eyeball, aggravated by motion. Dark red 
puffy face. Great dryness of the mouth and tongue. Thick 
white or brownish coating on the tongue. Bitter, sour taste. 
Excessive thirst for large quantities of water. Fullness and 
pressure in the epigastric region. Vertigo or nausea on sitting 
up. Dark, almost brown, scanty urine. Pull, hard, rapid pulse. 
Pain in the back, limbs, and abdomen. Worse in warm weather 
after cold days. 

Cadmium sulph. — Yertigo, nausea, pitch-like taste in the 
mouth; salty, rancid eructations. Burning and cutting in the 
stomach; vomiting of sour, yellowish or blackish fluid. Pain in 
the abdomen. Cold sweat on the face. 

Camphor. — Severe and long-lasting chill. Great anxiety and 
restlessness. Pale, anxious expression. Weak, scarcely percep- 
tible pulse. Icy coldness of the whole body. Cold, clammy 
sweat. Internal trembling; great prostration. 

Cantharis. — Insensibility. Yellowness of the conjunctiva. 
Suppression or retention of urine. Bloody, turbid, scanty urine. 
Pain in the loins, kidneys and abdomen. Tearing in the limbs; 
cold sweat on the hands and feet. Hemorrhage from the stom- 
ach and bowels. Convulsions with dysuric and hydrophobic 
symptoms. 



LEADING INDICATIONS. 217 

Carbo. reg. — Great restlessness; icy coldness of the whole 
"body. Pale, greenish-yellow color of the face; hippocratic coun- 
tenance. Pressive headache above the eyes. Pupils insensible 
to light. Severe and oft-repeated nosebleed. Dryness and raw- 
ness of the tip of the tongue. Sour, rancid eructations; burning 
and sensitiveness in the epigastrium with vomiting of blood. 
Flatulence; putrid, cadaverous, involuntary evacuations. Dark 
red, bloody urine. Difficult breathing; desire to be fanned. 
"Weak, small, thread-like pulse; cyanosis. Coldness of the 
breath; cold sweat upon the limbs. Ecchymoses. 

Cimicifuga. — Melancholy; fear of death; indifferent. Exces- 
sive pain behind the right orbit. Delirium, dreams about ne- 
groes, devils, etc. Yiolent pains in neck and back. Excessive 
muscular soreness. Weakness, trembling and spasmodic action 
of the muscles. Obstinate sleeplessness; waking from sleep 
with a start. Alternate tonic and clonic spasms. 

Colocyntk. — Dark redness of the face. Colic pains, relieved 
by pressure. Frequent urging to urinate with scanty urination. 
Drawing pain in the right thigh, down to the knee. Cramp in 
the left calf. Tendency to cramp in all muscles of the body. 
Night sweat smelling like urine. 

Crotalus. — Delirium with open eyes; utter apathy. Intense 
headache; with red, puffed face. Hemorrhage from all the ori- 
fices of the body. Bloody sweat. Deep yellow color of the whole 
cutaneous surface; ecchymoses. Coldness of the skin. Pulse 
•either slow or rapid and scarcely perceptible. Extreme depres- 
sion of vital powers. W T eak, hoarse, rough voice. Sour, acrid, 
eructations, nausea; bilious or bloody vomiting; bloody, some- 
times involuntary stools. Painful retention of urine. 

Cuprum acet. — Anguish with great restlessness. Convulsive 
and restless movements of the eyes. Blueness of the face and 
lips. Gurgling on swallowing. Excessive nausea; violent vom- 
iting; with pressure on the stomach, aggravated by touch and 
motion ; bloody vomiting. Spasmodic contraction of the abdom- 
inal muscles. Spasms and cramps in the calves. Clonic spasms. 

Eupatorium perf. — Headache, with sore feeling internally. 
Soreness of the eyeballs, with intolerance of light. Nausea 
with retching and vomiting of bile. Aching pain in the back, 



218 LECTURES ON FEVERS. 

as from a bruise. The bones ache as if broken. Trembling and 
nausea from the slightest motion. 

Gelsemium. — Dullness of the mental faculties. Vertigo with 
loss of sight; blurred vision. Fullness of the head, with heat 
in the face and chilliness. Heavy, dull, besotted expression. 
Thick, yellowish-white coated tongue ; difficult deglutition ; fetid 
breath. Frequent, soft, almost imperceptible pulse. Trembling 
in all the limbs. Loss of muscular power in the legs. Sleep- 
lessness; becomes delirious on falling asleep. 

Hyoscyamus. — Delirium and restlessness. Picking at the 
bedclothes. Pressing pain in the forehead; undulating sensa- 
tion in the brain, Red and sparkling eyes; dilated pupils. Dark 
red bloated face, Retching and vomiting; hiccough; tenderness 
over the epigastrium. Involuntary nocturnal stools; retention 
of urine. Convulsions; sleeplessness from excessive nervous 
excitement; wakes up with a cry. 

Ipecac, — Paleness and puffiness of the face; blue rings around 
the eyes. Vertigo, with chilliness and pain in the back and limbs. 
Distressing nausea, vomiting, predominance of gastric symptoms. 
Great weakness and anxiety. 

Lacliesis. — Nightly delirium; vertigo in the morning on awak- 
ing. Headache over the eyes and in the occiput; pressive head- 
ache with nausea. Rush of blood to the head with redness of 
the face; bursting pains in the temples. Yellowness of the con- 
junctiva; dimness of vision; black nickering before the eyes. 
Tongue, mouth and lips are red, dry and parched. Tongue is 
heavy and trembles when protruded. Neck sensitive to the 
touch. Sour eructations; nausea after drinkng; stomach sensitive 
to pressure. Foaming,, almost black urine. Oppression of the 
chest with shortness of breath. Irregular, weak pulse; palpita- 
tion of the heart; cramp-like pain in the precordial region. 
Sleepiness with inability to sleep; tossing and moving during 
sleep; symptoms worse after sleep. Great physical and mental 
exhaustion; attacks of suffocation. Perspiration at night; the 
sweat stains the linen yellow. The blood is dark and non-coag- 
ulable; small wounds bleed much, sore spots have a dark red, 
brownish appearance. 

Lycopodium. — Depression of spirits, with great anxiety. Press- 
ing or tearing frontal headache; worse from 4 to 8 p. m. Yellow- 



LEADING INDICATIONS. 219 

ish-gray color of the face. Gums bleed from the slightest touch; 
vesicles on the tongue. Acrid eructations; pressure and heavi- 
ness in the stomach; hiccough. Flatulent distension of the 
abdomen. Severe backache; fiequent desire to urinate; hem- 
orrhage from the kidneys and bladder. Shortness of breath, 
especially during sleep; soporous sleep. 

Mercurius. — Great anxiety and restlessness; weakness of 
memory; and moroseness. .Vertigo with violent headache; pres- 
sive pain in the left temple. Eyes red, inflamed, and sensitive 
to light, especially fire-light. Pufhness of the face; dirty yellow 
skin. Hemorrhage from the gums; fetid odor from the mouth. 
Tongue swollen, coated white, and showing the imprints of the 
teeth; profuse salivation. Region of the liver swollen and sen- 
sitive to pressure. Violent thirst, with vomiting of slime and 
bilious matter. Dark red, turbid urine. Weakness and weari- 
ness in all the limbs; coldness of the extremities. Glandular 
swellings. Perspiration stains the linen yellow. 

Nux vom. — Extreme sensitiveness to external impressions; 
great anxiety. Headache, with tension in the forehead, worse in 
the morning before opening the eyes. Eyes injected, yellow, and 
watery. , Yellowness of the skin; paleness or yellowness of the 
face. Heaviness of the tongue with difficult speech; dryness of 
the mouth; accumulation of mucus in the throat. Thirst for 
beer or stimulating drinks; tension and fullness in the epigastri- 
um; violent hiccough; bitter, sour eructations. Contractions of 
the abdominal muscles; small, slimy, bilious or bloody stools. 
Burning pain in the neck of the bladder, with difficult urination. 
Convulsions ; cramps in different parts of the body. 

Phosphorus. — Great indisposition; inability to think; low 
muttering delirium. Dull, pressive frontal headache; throbbing 
pain in the temples. Face puffy, and of a yellowish hue; blue 
rings around the eyes. Dry, red or black tongue. Constant 
nausea; vomiting of food and of blood, mingled with bile and 
mucus. Oppression and burning in the epigastrium. Hemor- 
rhages from various orifices of the body. Hematuria. Ecchy- 
moses. Petechia. 

Rhus tox. — Anxiety with great restlessness; apprehensive, 
with inclination to weep. Talkative delirium, or coma with rat- 
tling respiration. Dirty yellow color of the skin; sunken face; 



220 LECTURES ON FEVERS. 

■glassy eyes; dry, red and cracked tongue. Dryness of the throat, 
with great thirst for cold water or cold milk. Eructations and 
rumbling in the abdomen, causing great distress. Pressure and 
burning in the stomach with nausea and vomiting. Dark, brown 
stools, mixed with blood. Hot, scanty, high-colored urine. Ach- 
ing pains in the back and legs; constant restlessness and tossing 
about. Sleeplessness. 

Tartar emet. — Headache as from a band compressing the 
forehead. Red, or white and pasty tongue. Continuous nausea 
with great anxiety; intense and long-lasting vomiting; absence 
of thirst. Dark, reddish-brown, turbid urine; scanty urination. 
Rapid, weak, trembling pulse. Great weakness, with trembling 
of the whole body. Great sleepiness. 

Terelbinthina. — Headache with intense pressure and fullness 
of the head. Tongue red, smooth and glossy. Vomiting of mu- 
cus, bile or blood ; severe burning pain with excessive distension 
of the abdomen. Griping, pinching colic, with muco-purulent 
stools. Small, weak, thready pulse. Cold, clammy sweat, all 
over the body. Burning, drawing pains in the kidneys, with 
bloody urine. Strangury. Great prostration. 

Yeratrum alb. — Anxiety and oppression of spirits. Vertigo 
with cold perspiration on the forehead; coldness and pressure 
on the vertex. Face pale, or yellowish, cold and sunken; hippo- 
cratic countenance. Eyes dull, yellowish and watery ; surrounded 
by blue or black rings. Dryness of the mouth and palate ; cold- 
ness of the tongue; difficult swallowing; hiccough. Violent, 
forcible, excessive vomiting; vomiting of bile and blood. Great 
thirst, especially for cold water. Thin, blackish or yellowish, 
involuntary stools. Suppression of urine. Difficult respiration, 
with tightness and constriction of the chest. Small, scarcely 
perceptible intermittent pulse. Icy coldness of the hands arid 
feet. Extreme weakness and prostration. After over-closing 
with castor oil. 

Yeratrum vir. — Severe frontal headache with vomiting; 
headache proceeding from the nape of the neck. Intense fever, 
with flushed face and convulsive twitchings of the facial mus- 
cles. Dryness of the mouth and lips; tongue feels as if scalded, 
and is red in the middle and yellow at the edges. Violent nau- 
sea and vomiting with pain in the epigastrium. Cramps of the 



HYGIENIC AND DIETETIC TREATMENT. 221 

extremities. Coldness of the whole body. Threatened convul- 
sions, especially in children. 

HYGIENIC AND DIETETIC TREATMENT. 

The hygienic and dietetic treatment of yellow fever is almost 
as essential as is the medicinal. The sick-room should be large, 
well lighted and well ventilated. As soon as the first symptoms 
of the disease appear, the patient should be put to bed and kept 
in a state of perfect mental and bodily rest. One or two trusty 
friends maybe selected as nurses, but all unnecessary visiting or 
going to and fro in the sick-chamber must be strictly forbidden. 
Piatt's chlorides, thymol or some other disinfectant should be 
sprinkled upon the bed and about the room, several times a day. 

During the first twenty-four hours if the temperature exceeds 
104° Eahr., the cold bath may be used. After this time frequent 
sponging of the body, under the bedclothes, with whisky and 
water is preferable. In the beginning of the disease the hot 
foot-bath is quieting to the system and may prove advantageous. 
Copious enemata should be administered at the outset, every four 
or six hours, until two or three satisfactory discharges are ob- 
tained. Broken ice held in the mouth, will generally allay the 
distressing thirst, and is often very refreshing to the feverish 
patient. An infusion of orange leaves is a standard drink; it 
has a soothing and slightly diaphoretic influence. After the 
third or fourth day, milk and lime water or chicken broth may 
be given every two or three hours. When the stomach is very 
irritable, rectal alimentation should be resorted to. Daily ene- 
mas tend to remove the intestinal flatus and almost always re- 
lieve the vomiting. Hot water fomentations are of service when 
pains in the bowels appear, and are excruciating and persistent, 
Lumbar pain and threatened urinary suppression may be re- 
lieved by turpentine stupes. Ice-water injections into the rectum 
are sometimes successful in relieving urinary retention, but 
usually this is best accomplished by the use of the catheter. 

Stimulants are always needed in collapse, and in the sinking 
spells of nervous prostration following the disappearance of the 
fever. They may be used on the third day of the disease, or 
earlier if indicated. When called for, tablespoonful doses of 
iced chamjmgne or teaspoonful doses of brandy may be admin- 
istered every hour. When the stomach is very irritable, injec- 



222 LECTURES ON EEVERS. 

tions of beef -tea and brandy must be given. Later, after the 
irritability of the stomach has disappeared, milk-punch, ale or 
porter will prove useful. Indigestible food must be guarded 
against for some time after convalescence appears to be f ally 
established 



LECTUBE X\. 

Cerebro-Spinal Fever. 

Definition. — Cerebrospinal fever may be defined as a malig- 
nant, non-contagious, febrile affection of indefinite duration, due 
to an unknown external specific cause, and assuming a variety of 
forms, marked by local manifestations which pertain chiefly to 
the cerebro-spinal axis, usually prevailing in general or limited 
epidemics. It is characterized by sudden invasion; by intense 
headache, uncontrollable vomiting, and painful contraction of 
the post-cervical muscles; by cutaneous hyperesthesia, and fre- 
quently by a rash mostly herpetic and petechial ; by active de- 
lirium alternating with stupor, or stupor deepening into coma; 
and by bi-lateral deafness, great nervous depression and motor 
paralysis. Nearly half the cases die, and mostly from failure of 
the respiratory nerve centers ; those who survive three days, have 
a fair chance for recovery. After death, constant lesions of the 
pia mater of the brain and spinal cord are found. Relapses are 
common. 

Synonyms. — Epidemic cerebro-spinal meningitis. Cerebro- 
spinal typhus. Malignant purpuric fever. Petechial fever. 
Spotted fever. Congestive fever. Tetanoid fever. 

History. — This disease doubtless prevailed in Europe as early 
as the fourteenth century, but was erroneously described as a 
variety of typhus until shortly after the beginning of the pres- 
ent century. The first of the circumscribed epidemics which 
appeared nearly simultaneously in Europe and in the United 
States, started at Geneva, in Switzerland, in 1805, and at Med- 

(223.) 



224 LECTURES ON FEYEKS. 

field, Mass., in 1806. For ten years following this outbreak, it- 
prevailed either sporadically or in limited epidemics on both 
continents. In 1822 it appeared in Vesoul, France, and in 1823 
at Middletown, Conn., but was of short duration. Germany was 
visited for the first time in the winter of 1822-23. After a long 
interval the fever again appeared in Europe in the early part of 
1837, and prevailed every year thereafter, till 1850, in many 
places, from the Mediterranean to the Baltic sea. Between 1840 
and 1850 it was epidemic in nearly all the states of this country 
from the gulf coast to the Dominion of Canada. From 1854 to 
1861, it was epidemic in Sweden, and from 1859 to 1860 in Nor- 
way. In 1866 a most destructive outbreak appeared in England 
and Ireland. In 1860 the disease reappeared in this country, 
and prevailed with great intensity among the troops during the 
civil war. A transient epidemic occurred in Canada in 1870, and 
it prevailed quite extensively in New York. Since 1873 it has 
not appeared here as an epidemic. It has never appeared within 
the tropics. The greatest number of epidemics have lasted from 
three to six months. And usually the fatality is in inverse ratio 
to the duration of the epidemic. Cerebro-spinal fever is by no 
means limited to the human race. On the contrary, it frequently 
becomes epidemic among the lower animals. 

Etiology. — The causes of this disease are of two kinds: pre- 
disposing and exciting. 

1. The predisposing causes. — Age being the most prominent,, 
merits first mention as a predisposing cause. The fever is by 
far the most common in the first two decades of life; the liability 
being greatest after seven years of age. The death rate is higher 
during childhood than at any other period. After middle life 
there is nearly an immunity. 

The seasons exert considerable influence upon the spread of 
the disease. Epidemics occur oftener in the winter and spring 
than during the summer months, and generally low tempera- 
tures are favorable to the existence and spread of the fever 
poison. 

Modes of life have much to do with the development and 
prevalence of the fever. It occurs largely among those who by 
reason of poverty or other cause, are subjected to privations un- 
der unfavorable hygienic conditions. Damp, over-crowded, 



ETIOLOGY. 225 

badly-ventilated, and unclean habitations, especially favor it. 
Invalids are not particularly predisposed; on the other hand, 
those attacked are frequently healthy and robust. Over-work, 
excitement, mental and bodily fatigue, combined with irregular- 
ity in eating, renders the system extremely susceptible. Statis- 
tics show that active military life is a powerful causative condi- 
tion. 

2. The exciting cause. — The exciting cause of cerebro-spinal 
fever remains as yet unknown, although it is generally believed 
to be atmospheric. Ziemssen speaks of it as a morbific germ, 
which primarily arises in the human body, and infects healthy 
neighbors only when it has undergone a certain, still unknown, 
modification by means of cultivation in suitable intermediate 
individuals. The theory of its parasitic origin has received 
considerable impetus from the recent discovery of bacterial 
forms — schizomycetes — in the pia mater after death. Cerebro- 
spinal fever is generally believed to be non-contagious. 

Varieties. — This "chameleon-like disorder," as Stille has 
been pleased to term it, admits of classification into the following 
four varieties: — 

1. The simple or ordinary variety, which represents the gen- 
eral course of the disease, and which will be fully described in 
the clinical history. 

2. The abortive variety, which occurs at the height and during 
the decline of all epidemics; is characterized by headache, spi- 
nal stiffness, malaise, and, as a rule, absence of fever; and rarely 
lasts longer than from five to seven days. 

3. The intermittent variety, which is characterized by inter- 
missions and exacerbations, the disease assuming the quotidian 
or tertian type. The intermittency frequently lasts for weeks, 
and suddenly terminates either in death or«recovery. 

4. The fulm inant variety, which occurs with greatest frequency 
at the beginning of epidemics, and which generally terminates 
in death within a few hours. In this fatal form of the disease, 
the onset is sudden, usually with a violent, shaking chill. Im- 
mediately, the patient becomes cyanosed, and the skin cold and 
shrunken. There is contraction of the neck, and purpuric 
blotches appear on the surface of the body. The urine is scanty 
and loaded with albumen. The respirations are slow and labored. 



226 LECTUKES ON FEVEES, 

and the pulse becomes rapid and faint. The headache alternates 
with drowsiness, and rapidly gives way to coma and death. 

Clinical History. — Cerebro-spinal fever, though occasionally 
preceded by a prodromal stage, of from a few hours to several 
days duration, marked by chilliness, headache, muscular pains 
and general languor, ordinarily begins abruptly with chilliness 
or a distinct chill, followed immediately by pronounced symp- 
toms. In children a convulsion frequently takes the place of 
the chill. The patient at once takes to the bed, is restless and 
complains of violent headache, vertigo, and vomiting, especially 
on rising, with slight nausea. During the intervals of vomiting 
a sensation of depression or faintness in the epigastrium is fre- 
quently experienced. The face is usually pale or cyanotic, the 
countenance distressed, the conjunctiva injected, and the pupils 
abnormally dilated. Dragging pains are soon experienced in the 
neck, along the spine, and in one or both extremities; and are 
rapidly followed by ionic contraction of the post-cervical muscles. 
At times this muscular contraction extends to the muscles of the 
trunk, abdomen and lower extremities. The patient lies with the 
head drawn back, the spine rigid, straightened — orthotonos — 
or curved— sometimes into complete opisthotonos— and with the 
arms, thighs, and legs Hexed. The entire cutaneous surface, but 
more especially the skin of the face, forehead and neck, is ex- 
tremely sensitive to touch and pressure. Intense sickening 
neuralgic pains in the chest and abdomen frequently occur. 
There is loss of taste, and the tongue is covered with a thin, 
whitish fur; exceptionally it is dry and brownish. In addition, 
there is extreme sensitiveness to light and noise. As the disease 
progresses the intense headache alternates with or gives way to 
passive or active delirium, which in a short time passes into 

coma. 

• 

The fever is atypical and irregular, aud usually reaches its 
maximum — 105° Fahr. to 107° Fahr, — in the first days of the 
disease. The temperature of the extremities is extremely varia- 
ble; more so than in any other affection. The pulse maybe 
either normal, rapid, or only moderately quickened. Its remark- 
able variation as to frequency and tension is almost characteristic. 
The respirations are at first quickened ; later they may become 
intermittent, sighing, and irregular. In fatal cases they may 



ANALYSIS OF CHAKT. 227 

present that alternation of respirations with respiratory pauses, 
known as Cheyne- Stokes respiration. 

After the first few days, herpetic spots are apt to appear upon 
the face, especially along the branches of the fifth pair of nerves; 
while petechial, erythematous and urticarial eruptions are not 
uncommon. The bowels are generally constipated; towards the 
close of the attack, diarrhea and involuntary evacuations may 
occur. All the symptoms develop rapidly, and reach their full 
intensity from the third to the sixth day. After the disease has 
lasted some time the patient may pass into that condition termed 
the typhoid stale; a condition usually marked by stupor or re- 
mitting delirium, a dry, cracked tongue, sordes on the lips and 
teeth, a small, rapid pulse, and involuntary evacuations. 

If the attack is to terminate fatally, the symptoms of nervous 
excitation yield to those of depression. The rigidity disappears; 
the pulse becomes rapid, small and scarcely perceptible ; and the 
temperature rises to 105° Fahr. or 108° Fahr. The patient 
passes into a state of stupor; convulsive muscular movements or 
paralysis occur; the stupor deepens into coma, and death super- 
venes. 

In favorable cases, the symptoms of depression are less marked 
and of shorter duration. Early in the disease the vomiting 
•ceases, the back and head pains subside ; and the rigidity disap- 
pears. The strength slowly returns, and the patient enters upon 
a gradual, somewhat protracted convalescence. A recurrence of 
vertigo and headache, during convalescence, is of serious im- 
port, and, when associated with vomiting and convulsions, points 
to the development of hydrocephalus. 

ANALYSIS OF CHAKT. 

The Nervous System. — The chill which ushers in the attack 
may be nothing more than a chilly sensation; usually it is pro- 
nounced, at times violent and oft repeated, and may last from 
one to two hours. In the majority of instances it appears ab- 
ruptly, in the evening, during the night, or on rising in the 
morning. 

Headache is one of the earlier and more persistent symptoms 
of the disease. It is generally severe in character, and gives 
rise to great restlessness and anxiety. It may be located in the 
forehead, occiput, temples, or extend over the whole head, and 
is of a beating, boring, stabbing character. As it usually con- 



228 



LECTURES ON FEVERS. 

CHAKT X. — Cerebrospinal Fever. 



Nature : 


Epidemic. Non-contagious. 


Varieties : 


Simple: 


Abortive : 


Intermitt- 
ent. 


Fulminant: 


Initial Symptoms: 


Vomitina' on ris- 
ing. Chill. Pros- 
tration. 


Sleepiness. 


Vertigo. 
Prost'tion 


Violent chill. 
Vomiting. Pros- 
tration. 


Duration: 


1 to 2 weeks. 


5 to 7 days. 


Several 
Aveeks. 


12 hours to 3 days. 


Head: 


Headache on the 
first day. 


Headache. 


02 

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& g 

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1 £ 

5' 3* 

3 o 

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p a> 

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Intense headache. 


Nervous System : 


Restlessness. De- 
lirium. 


Sleeplessness. 


Delirium. 

Coma.Convulsions 

Co/lapse 


Spine: 


Rigidity of post- 
cervical muscles. 
Orthotonos. 


Stiffness in neck 
and spine. 


Contraction of 
neck. 


Extremities: 


Rigidity. 

Neuralgic pains. 
Paralysis 


Stiffness and 
Contractions. 


Muscular rigidity 
Paralysis. 


Tongue : 


Coated white, 

moist; later, dry 

and brown . 


Coated white. 
Moist. 


Dry and brown . \ 
Sordes. 


Stomach: 


Thirst. Anorexia. 
Bilious vomiting. 


Vomiting. 


Nausea and 
vomiting. 


Bowels : 


Neuralgic pains. 
Constipated. 


Constipated. 


Neuralgic pains. 
Involuntary evac- 
uations 


Skin: 


Hyperesthesia . 
Herpes. Petechire- 


Hyperesthesia. 


Hyperesthesia 
Purpuric blotches. 
Superficial eangrene. 


Face: 


Usually pale. 


Pale. 


Shrunken, livid. 


Eyes: 


Photophobia. 
Conjunctiva in- 
jected Strabismus 


Conjundtiva red- 
dened. 


Deep-sunken eyes. 

Purulent choroid-, 

itis. 


Ears: 


Humming and 

ringing. Bi-lateral 

deafness . 


Humming in ears. 


Deafness. 


Temperature : 


99.5-" to 104° Fahr. 
Atypical. 


Seldom above 
normal. 


105° to 107° Fahr. j 


Pulse: 


Extremely varia- 
ble. 40 to 150. 


Variable. 


Variable. 
Weak and rapid. 


Respiration : 


Accelerated. 
Irregular. 


Easy. 


Slow and labored 
Arythmic 


Urine: 


Increased. 


Increased. 


Scanty. Albu- 
minuria. 


Convalescence: 


Irregular and un- 
certain. 


Early. 


Seldom attained. 


Complications : 


Croupous pneumonia. Endo and peri-carditis. Pleuritis. 
Parotitis. Intestinal catarrh. 


Sequels : 


Debility. Weakness of memory. Local paralysis. 
Deafness. Hydrocephalus. 


Prognosis : 


The mortality vai'ies from 20 to 75 per cent. 


Lesion: 


Fibrinous or purulent exudation in meshes of cerebro-spinal 
pia mater. 



ANALYSIS OF CHART. 229 

tinues throughout the attack, its cessation, unless followed by 
•coma or collapse, is a most favorable indication. In a large per- 
centage of cases, mental or bodily fatigue will bring on severe 
headaches long after convalescence has been fully established. 

Vertigo occurs as one of the prodromal symptoms, and is fre- 
quently associated with the headache. Recurring during con- 
valescence, vertigo and headache, especially when associated 
with vomiting and convulsions, are of unfavorable omen, as 
indicating the development of hydrocephalus. 

The pupils may be contracted at the outset and dilated at the 
close of an attack; not unfrequently they differ in size. There 
is almost constant photophobia; occasionally, nystagmus and 
transitory strabismus are observed. Conjunctivitis is of fre- 
quent occurrence. When it is severe there is marked chemosis, 
with opacity and ulceration of the cornea. At times, in conse- 
quence of severe suppurative irido-choroiclitis or optic neuritis, 
there is permanent and complete loss of sight. 

The ear symptoms, which are usually bi-lateral, consist of pain, 
liumming and ringing in the ears, followed by partial or com- 
plete, temporary or permanent deafness. They are due either 
to a catarrhal or purulent inflammation of the middle ear, or to 
suppurative inflammation of the labyrinth. 

Delirium, often transient, at times alternating with periods of 
stupor, is present in almost all severe cases after the second or 
third day. In mild cases it is slight, and occurs mostly at night; 
in fatal cases it becomes continuous, and finally passes into the 
•coma which precedes death. In the worst forms, coma may occur 
without the intervention of delirium. 

Convulsions are not infrequently met with in children, replac- 
ing the initial chill. They vary in degree from simple muscular 
twitchings, to violent epileptiform seizures. If long continued, 
they render the prognosis unfavorable. 

Paralysis, located in the muscles of deglutition and articula- 
tion, or affecting one or both extremities, occurs in a small pro- 
portion of cases. It usually develops towards the close of the 
disease, and may either disappear in a few days or last for years. 

Stiffness of the neck, caused by contraction of the deep cervi- 
cal muscles, is a marked characteristic. It appears mostly be- 
tween the second and fifth days, and lingers far into convalescence. 
It varies greatly in degree, from a slight stiffness noticeable only 



230 



LECTUKES ON EEVEKS. 



when attempting to ilex the head, to a contraction so great that 
the vertex is drawn down between the shoulders, at almost a 
right angle with the spine. In the worst cases swallowing is- 
rendered extremely difficult and painful. In exceptional cases* 
this stiffness of the neck may be absent. It is generally regarded 
as a reflex contraction due to inflammation of the pia mater of 
the medulla, and of the posterior columns and roots of the cer- 
vical portion of the cord. 

Contraction of the other erector muscles of the spine is present 
in a large proportion of cases, and varies in degree from a mere 
stiffness, and straightening of the spine (orthotonos), to a draw- 
ing of the trunk into so distinct an arch that the body rests only 
upon the occiput and heels (opisthotonos). Orthotonos is o£ 
frequent occurrence, while complete tetanoid opisthotonos and 
pleurosthotonos (unilateral contraction of the spinal muscles) 
are extremely rare. The duration of the contraction is very va- 
riable. In favorable cases it disappears in from a few days to 
two or three weeks; not unfrequently it continues from four to 
six weeks. Trismus has been observed only in patients who are 
dangerously ill and comatose, and is an unfavorable symptom. 
Stiffness and contraction of the muscles of the extremities is 
not uncommon^ present. 

Fig. 14. 




Attitude of the Patient in Severe Cerebrospinal Fever (After Smith). 
In consequence of these muscular rigidities the usual attitude 
of the patient in bed (Fig. 14), is with the head drawn back, the 
spine straightened or arched forward, the forearms flexed upon 
the arms, the legs upon the thighs, and the thighs drawn up 
upon the abdomen. 



ANALYSIS OF CHABT. 231 

Pains in the spine (rachialgia), neck, loins and legs, occurring 
in exacerbations and remissions, are frequent symptoms. They 
vary considerably in intensity and duration, and are often inten- 
sified by attempted movements. Inflammation of the wrist-joints 
is occasionally met with. 

The Cutaneous Surface. — Hyperesthesia of the skin though 
not a constant symptom, is thoroughly characteristic when pres- 
ent. It usually appears as early as the second or third day, and 
is most marked on the anterior surface of the lower extremities. 
It is often so severe, that the simple movement of the limbs, the 
mere touching of the surface of the body, or even the slightest 
shaking of the bed, will give rise to expressions of pain and 
suffering. 

Cutaneous eruptions developing symmetrically are oftener 
associated with cerebro-spinal fever, in this country than in Eu- 
rope. Of these herpes, commencing usually about the second or 
third day, upon the lips and extending over the face, and at times 
appearing upon the trunk and extremities, is the most common. 

Petechial and ecchymoses are not infrequent manifestations. 
When present, they produce a more or less distinct, widely dif- 
fused mottling of the whole surface. Other forms of eruption 
occasionally observed are, roseola, erythema, urticaria, erysipe- 
las and sudamina. Sometimes a patient presents three or four 
separate forms of cutaneous eruptions. 

The Temperature. — The course of the fever is irregular and 
the temperature curve is atypical. It is apt to have attained 
considerable elevation as early as the second or third day. After 
the disease has become fully established its average range in 
adults is from 100.5° Fahr. to 104° Fahr. ; in children it is some- 
what higher. Exacerbations of pain may cause a rise of two or 
three degrees. In rapidly fatal cases it may reach 107° Fahr. or 
even 110° Fahr., as death approaches. Defervescence, rarely 
rapid, usually takes place by a gradual fall (lysis); a rapid fall 
almost invariably ushers in collapse and death. The difference 
between the morning and evening temperatures is neither as 
marked nor as constant as in most other fevers. 

Wunderlich distinguishes three special fever courses: — 
1. "In some very severe and rapidly fatal cases the tempera- 
ture, though not invariably very high at the beginning of the 



232 LECTURES ON FEVERS. 

disease, reaches very striking heights in the briefest time. It 
remains high, rising even higher at the approach of death, till 
in the very moment of death it may attain 107.6° Fahr. or more. 
In one of his cases it reached 110.7° Fahr. It may rise some 
tenths of a degree after death. In some fatal cases the temper- 
ature may remain very moderate for some time, and rise rapidly 
and with abruptness at the close of life. 

2. " On the other hand, relatively mild cases exhibit a fever of 
only short duration, although there are sometimes considerable 
elevations of temperature and often an interrupted course. Re- 
covery does not take place by crisis, but happens rather with a 
remittent defervescence (lysis). Here and there cases occur 
which, after defervescing and apparently almost recovering, re- 
lapse all at once with a rapid rise of temperature and run a 
course like those marked (1). 

3. " In contrast with these brief courses of fever with either 
very severe or slight character, we find cases which are more or 
less protracted. The height of the temperature in these may 
be varied, and indeed exhibit manifold changes in the very same 
case, though this chiefly depends upon the varied complications 
which supervene in the shape of bronchial, pulmonary and in- 
testinal affections, and affections of serous membranes." 

The Circulatory and Respiratory Systems. — The pulse is 
extremely variable, and bears no constant relation to either the 
height of the fever, or the gravity of the other symptoms. As 
a rule, especially in children, it rises with the onset of the fever, 
and in fatal cases is often so rapid that it cannot be counted; 
occasionally it remains normal; and but rarely it is retarded. 
Its most constant character is its varicdions in rapidity. It may 
show a difference of thirty or forty beats in a few hours; and 
sometimes even within a few minutes it may vary twenty or 
thirty beats. Continued rapidity is to be regarded as unfavor- 
able. 

The respirations sometimes remain undisturbed in mild cases. 
They are usually sighing, labored and interrupted in grave cases. 
Tne Cheyne-Stokes respiration is supposed to be due to pressure 
upon, or oedema of the medulla oblongata. Catarrhal affections 
of the upper air passages are not uncommon. 

The Digestive Tract. — The tongue is moist and coated with 



MORBID ANATOMY. 233 

a whitish fur at the beginning of the fever and during deferves- 
cence. At the height of the disease it may become dry and 
brown. The teeth and lips are frequently covered with sordes. 
Vomiting is an early and frequently recurring symptom. It 
may occur without previous nausea, and is excited by movement, 
particularly by rising. Thirst and anorexia are strongly marked. 
Constipation is the rule. Jaundice is present in a small number 
of cases. Parotitis is considered a possible, but infrequent ac- 
cident of the disease. 

The urine is increased in quantity and loaded with urates; 
occasionally it contains a moderate amount of albumen. Polyu- 
ria is frequently observed, especially in children. 

Complications and Sequels. — The complications of cerebro- 
spinal fever vary in different epidemics, and at different stages 
of the same epidemic. The most frequent are: catarrhal and 
croupous pneumonia, bronchial catarrh, pleuritis, endo-carditis, 
peri-carditis, intestinal catarrh, choroiditis with consecutive de- 
tachment of the retina, and purulent inflammation of the laby- 
rinth and tympanum. The more important sequels are : deafness, 
derangements of vision, general debility, boils and carbuncles, 
paralysis, weakness of memory, and chronic hydrocephalus. 

Morbid Anatomy. — The lesions of cerebro-spinal fever, which 
are due in part to the direct action of the morbific agent upon 
the blood, and in part to the inflammation, are quite constant 
and vary only in the degree of their development. The blood 
contains more fibrin than normal, the amount varying according 
to the extent of the inflammation. In malignant cases it is 
usually dark and fluid, and contains a few dark and soft clots. 
Bubbles of gas have been observed occasionally in the large 
vessels and in the cavities of the heart, a few hours after death. 
The heart is often flabby, and exhibits changes due to granular 
degeneration. The pericardium is sometimes inflamed, and cov- 
ered with a purulent exudation; recent endocarditis is rarely 
observed. The lungs, in a certain proportion of cases, exhibit 
changes, such as hyperemia, oedema, patches of atelectasis as a 
result of capillary bronchitis, and infiltrations of catarrhal and 
less frequently of croupous pneumonia. Serous transudations, 
sometimes blood-stained, occasionally occur in the pleural and 
other serous cavities. 



234 LECTURES ON FEVEKS, 

The brain and the meninges are intensely congested in cases 
which are speedily fatal. The cranial sinuses are engorged with 
dark fluid blood, containing soft post-mortem clots, or firm 
thrombi. The arachnoid membrane may remain unchanged in 
rapidly progressing cases; it may appear hypersemic and blood- 
stained, or dry, lustreless and opaque ; occasionally, as after pro- 
longed illness, it becomes rough and thickened. The pia mater* 
which is the seat of the primary inflammation, is for the first 
few hours hypersemic and adherent to the surface of the brain. 
After the second or third day, a yellowish or greenish, butter- 
like exudation, consisting mainly of fibrin, mucine, pus-cells and 
free granules, and varying from one to four lines in thickness, is 
found to occupy the sub-arachnoid space. The exudation is most 
abundant in the fissures and depressions along the course of the 
vessels, upon and around the optic commissure, and also upon the 
pons and medulla oblongata. In cases of great severity the ex- 
udation of fibrin and pus may occur over nearly every part of 
the cerebral surface. The amount of serous exudation varies 
greatly in different cases; it may be so small as to scarcely at- 
tract attention; or it maybe so large, in children, as to cause the 
head to present all the appearances of ordinary congenital hy- 
drocephalus. The brain substance is frequently congested, and 
localized cerebral softening is not uncommon. The ventricles, 
especially in protracted cases, are found to contain more or less 
turbid serum, and at times pus. The membranes of the cord 
present changes similar to those of the meninges of the brain. 
The pia mater is roughened and thickened, and is intimately ad- 
herent to the cord. The exudation appears first as cloudy serum,, 
then as bands of fibrino-pus, and lastly as thick layers of pus. 
It is seated mostly on the posterior surface of the cord, and is 
most abundant in the lumbar region. The substance of the cord 
may present changes similar ,to those observed in the encepha- 
lon, such as hyperemia, serous infiltration, and softening. 

The muscles, especially those extending along the spinal col- 
umn, are found to have undergone granular degeneration. The 
kidneys are, as a rule, congested; at times the tubules are 

*The changes in the pia mater may possibly be due to certain scMzomycetes, 
which finding in it their necessary nourishment, cause by their development 
and growth such chemical changes that the walls of the capillaries of the pia 
become altered in structure. 



DIFFERENTIAL DIAGNOSIS. 235 

blocked witli fat granules and fibrinous casts. Emaciation is 
strongly marked, especially in protracted cases. Post-mortem 
rigidity is usually marked and of long duration. The skin dis- 
plays herpetic crusts and petechial .stains; more or less extensive 
and deep discolorations of the dependent parts of the body rap- 
idly appear. 

Differential Diagnosis. — The diagnosis of cerebro-spinal fe- 
ver is usually attended with but little difficulty during the prev- 
alence of epidemics. It is, however, far from easy when sporadic 
cases occur, either within the limits, or at the beginning of an 
epidemic, or when very young infants are attacked, or when it 
develops as an intercurrent affection in the course of other 
acute diseases such as croupous pneumonia and typhoid fever. 
Of diagnostic importance are, early in the disease, the sudden 
onset of the symptoms, the headache, the vomiting, the pains in the 
neck, spine and calves of the legs, the stiffness of the cervical and 
spinal muscles, the retraction of the head, and the general cuta- 
neous hyperesthesia; and later, the herpes, the restlessness and 
delirium, the tetanic spasms, the irregular temperature and the 
variable pulse. 

It may be simulated by tuberculous basilar meningitis, typhus 
fever, typhoid fever, scarlet fever, pernicious fever, masked 
small-pox and tetanus. 

Tuberculous basilar meningitis is distinguished by its gradual 
approach, and slow course, and by its generally appearing in 
patients of a scrofulous or tuberculous diathesis. It presents no 
characteristic cutaneous eruption; but when the finger is drawn 
across the skin of the forehead it leaves a vivid red mark. The 
delirium is usually transitory, and there may be slight temporary 
paralysis as shown in imperfect co-ordination of muscular move- 
ments, but no tetanic spasms. The paralysis may affect the op- 
tic commisure and oculo-motor tracts. Ophthalmoscopic ex- 
amination will reveal, more especially when general tubercular 
disease exists, tubercles of the choroid with neuro-retinitis. 
When tubercular meningitis attacks the convexity there is a con- 
stant convulsive condition, moderate force, and very variable 
pulse. 

Typhus fever and typhoid fever present well-marked points 
of contrast with cerebro-spinal fever, which, for the purposes of 
differentiation, may be arranged in tabular form as follows : — 



236 



LECTUEES ON FEVEKS. 



TYPHUS FEVEE. 

An epidemic disease. 
Highly contagious. 
Onset sudden- 
Occurs at all ages. 
Occurs at all seasons. 
Duration, about 14 days. 

Defervescence, critical or 

by rapid lysis. 
Belapses, rare. 
Countenance, dusky-red. 

Pupils equal and con 
tracted 

Strabismus rare. 

Deafness seldom perma- 
nent. 

Skin emits an ammoniacal 
odor. 

Mulberry rash, rarely ab- 
sent. 

Appears on 5th or 6th day. 
Ecchymoses, rare. 
Headache, dull or heavy. 

Delirium rarely absent. 
Begins at end of first 
week. 

Temperature range, typi- 
cal. 

Pulse, soft; 100 to 140. 

Vomiting, rare. 

Tetanic spasms absent. 
Pains, dull and muscular. 



Emaciation slight. 
Blood never fibrinous. 
No constant lesions. 

Mortality, 15 to 50 per cent 



CEEEBEO-SPIXAL FEVEE 

A pandemic disease. 
Non-contagious. 
Onset sudden 
More in young persons. 
Occurs generally in winter. 
Duration, indefinite; usu- 
ally from 4 to 7 days 
Bemittent defervescence. 

Belapses, common. 
Countenance, usually pale 

or cyanotic 
Pupils unequal. 

Strabismus common. 
Deafness often permanent. 

Skin has no peculiar odor. 
Cutaneous hyperesthesia. 

Eruptions various; mostly 
herpetic and petechial. 

Appeals on 1st or 2d day. 

Eccbymoses, common. 

Headache, acute and ago- 
nizing. 

Delirium often absent. Be- 
gins on first or second 
day. 

Temperature fluctuating 
and atypicaL 

Pulse variable, frequently 
slow. 

Bilious vomiting a con- 
stant symptom. 

Tetanic spasms frequent. 

Pains sharp, lancinating 
and neuralgic in charac- 
ter, in spine and extrem- 
ities. 

Emaciation marked. 

Blood highly fibrinous. 

Constant lesions of the cer- 
ebro-spinal pia mater. 

Mortality 20 to 75 per cent. 



TYPHOID FEVEE. 

An endemic disease. 

Non-contagious. 

Onset insidious. 

More in early adult life. 

Occurs mostly in autumn. 

Duration from 3 to 4 weeks. 

Defervescence by prolonged 
lysis. 

Belapses, occasionally. 

Countenance, pale or pur- 
plish-red. 

Pupils equal, often dilated. 

Strabismus absent. 
Deafness occasionally per- 
sistent. 
Skin has a musty odor. 



Rose-rash, seldom absent. 

Appears on 7th to 9th day. 
Ecchymoses, rare. 
Headache, dull. 

Cerebral symptoms ap- 
proach gradually. 

Temperature range, typi- 
cal. 
Pulse, 100 to 140. 

Vomiting, occasional. 

Tetanic spasms rare. 
Pains, dull and m oscular. 



Emaciation great. 
Blood rarely fibrinous. 
Constant lesions of ileum 

and mesenteric glands. 
Mortality 15 to 20 per cent. 



PROGNOSIS. 237 

Scarlet fever may, in the early hours of invasion, present many 
of the initial symptoms of cerebro-spinal fever, The early red- 
ness of the middle of the soft palate, and the rapid appearance 
of the scarlatinal rash, will usually enable the diagnosis to be 
made with certainty. 

Pernicious fever may be confounded with the fulminant vari- 
ety, or with either of the other varieties as they approach con- 
valescence. The main points of difference may be summarized 
as follows: — 

CEREBROSPINAL FEVER. I PERNICIOUS FEVER. 



A pandemic disease. 

Chiefly among children. 

Occurs mostly in winter. 

Inceptive chill appears suddenly: usu- 
ally without prodromes. 

Face pale or cyanotic. 

Eruption on first or second day. 

The fever rise shows marked irregular- 
ity. 

Constipation the rule. 

Muscular contractions the rule. 

Blood highly fibrinous; absence of pig- 
ment. 

Spleen slightly enlarged. 



An endemic disease. 

Common to all ages. 

Occurs mostly in spring and fall. 

Initial chill, usually preceded by an 
intermittent fever paroxysm. 

Complexion sallow. 

Xo eruption. 

The fever rise shows marked periodic- 
ity. 

At times diarrhoea. 

Muscular contractions rare. 

Blood lacks fibrin, but contains free 
pigment. 

Spleen enlarged and softened. 



Masked small-pox, which at times resembles this disease, may 
be recognized by the absence of tetanic spasms of the post-cer- 
vical muscles. True tetanus is distinguished by the absence of 
epidemic influence, by the history of the case, by the absence of 
fever, and by the clearness of the mental faculties. 

Prognosis. — The prognosis can never be made with certainty, 
as the course of the disease is extremely variable. The abortive 
and fulminant varieties run a rapid course, and terminate in 
from one to five days. The simple and intermittent varieties 
may run their course in from one to two weeks or they may last 
for months. As a rule, the first week is the period of greatest 
danger. The usual termination in fulminant cases is death. A 
steady amelioration of all symptoms within the first or second 
week, in mild or moderately severe cases, renders a favorable 
prognosis possible. Unfavorable symptoms are : intense excite- 
ment, early appearance of symptoms of depression, return of 
the vomiting, intense headache, deep and persistent coma, ex- 



238 LECTURES ON FEVERS. 

tensive petechia, recurring convulsions, and irregular respira- 
tion. Relapses are not infrequent, and often prove fatal. 

The ratio of mortality varies greatly in different epidemics, 
but averages about forty per cent. In the majority of cases, 
death takes place by failure of the respiratory nerve-centers. 



LECTUKE XVI. 

Cerehro-spinal Fever.— ( Continued. ) 

TREATMENT. 

Prophylaxis. — Statistics show that cerebrospinal fever ap- 
pears most frequently, assumes, as a rule, its worst form, and 
numbers its largest percentage of victims where sanitary re- 
quirements are most neglected. Attention should, therefore, 
be given to proper sewerage and drainage, and to the prompt 
removal of all refuse and decaying matter from the streets and 
dwelling places. During an epidemic, unusual mental and bod- 
ily fatigue, and all irregularities in the mode of life, should be 
strictly avoided. Argentum nit. is recommended as a preventive 
for the simple variety and arsenicde of quinine for the intermit- 
tent form. 

Principal Remedies.— The remedies that oftenest claim atten- 
tion at the outset of an attack, are veratrum vir., gelsemium, 
belladonna and solanum nigrum. 

Veratrum vir. is adapted to severe cases, and more especially 
when there is intense brain congestion with nausea and vomiting, 
a hard, full, bounding pulse, and marked opisthotonos. Gelsem- 
ium is indicated in mild cases, and such as are attended by a 
lesser degree of inflammation of the meninges. The pulse is usu- 
ally quick, full and soft, the headache is heavy in character, and is 
located mainly in the occipital region, Belladonna may be em- 
ployed when there is more or less active delirium, with redness 
of the face and eyes, and alternately contracted or dilated pupils. 
Solanum ui(j. takes the place of bell., when spasms and convul- 

(239) 



240 LECTURES ON FEVERS. 

sions mark tho onset of the disease. Rhus tox. will be needed 
when a typhoid state supervenes, and especially when the cuta- 
neous eruptions are of a multiform character. In the last stages 
when there is a tendency to coma, opium should be given. 

For the intermittent variety in the first stages, cedron, arseniede 
of quinine and the picrcde of ammonia are important remedies. 
When the typhoid state is engrafted on this variety, and there is 
great restlessness and extreme prostration, arsenicum alb. will 
be needed. 

In fulminant cases, where the chill is prolonged and there 
seems to be no power of reaction, camphor should be given. 

Crotalus may at times render valuable service in these cases, 
particularly when the petechial phenomena are prominent. Se- 
cede is a noteworthy remedy for the internal congestion, the con- 
vulsive shocks and the tetanic phenomena. 

Verat alb. or mix vom. may be needed for the electric-shock- 
like pains in the abdomen and extremities. Cicida for tonic 
spasms of all the muscles of the body, with gastralgia and vio- 
lent vomiting. Cimicifuga when spasms and obstinate vomiting 
continue after the acute symptoms subside. Digitalis when the 
heart's action is irregular and labored, and the urine is dimin- 
ished in quantity. Physostigma when there is contraction of 
the pupils, with a tumultuous, irregular and feeble heart, tetanic 
rigidity, and retraction of the head. 

Bapiisia may be administered as an intercurrent remedy in 
the typhoid state, when general paralysis threatens, the excre- 
tions become offensive, and the blood rapidly tends to disorgan- 
ize. Helleborus is called for when there are indications of serous, 
effusion, and when the phenomena of paralysis have become 
complete. Igncdia and cannabis ind. deserve attention when 
there are hysterical symptoms or complications. Phosphorus 
must be employed when pneumonic complications exist, and when 
there are extensive petechiae. 

During convalescence, zincum or anacardium for weakness of 
memory; plumbum or cuprum for paralysis; and silicea or sul- 
phur for deafness, may be needed. 

Leading Indications. — Aconite. — During or after the chill. 
Dryness of the skin, with restlessness and great thirst. A quick, 
hard, sharp pulse (bell). Tearing in the nape of the neck;, 



LEADING INDICATIONS. 241 

stiffness of the back (rhus). Despairing mood and fear of 
death (ars.). In plethoric individuals. 

JEthnsa cyn. — Vertigo with a tendency to stupor and coma; 
obstinate vomiting. Tearing, lancinating, beating pains in the 
occiput, extending all over the head. Face pale and collapsed; 
eyes staring; pupils dilated and insensible to light (hyos.). Epi- 
leptiform convulsions. During dentition. 

Agaricus muse. — Vertigo; great weight in the occiput; the 
head constantly falls backward. Great weight in the forehead 
and temples with delirium and coma. Twitching of the eye- 
lids and eyeballs. Twitchings of the facial muscles; painful 
sensitiveness of the scalp. Stiffness and sensitiveness of the 
nape of the neck and spine. Yiolent, burning, shooting pains 
deep in the spine. Paralysis of the upper and lower limbs . 

Ammonium carb. — Oppressive fullness in the forehead and 
vertex, as if the head would burst. Ringing in the ears; swell- 
ing of the parotids (mere). Painful stiffness of the neck and 
small of the back. Weak, nervous individuals and scrofulous 
children 

Anacardium. — Loss of memory; weakness of all the senses 
. (phos. acid, zincum). Dull pressure as with a plug on the left 
side of the vertex. Cramps in the calves when walking; knees 
feel paralyzed. Hypochondriasis {lye). 

Apis niel. — Headache with vertigo; brain feels tired; burning 
and throbbing in the head, relieved by pressure. Sopor inter- 
rupted by piercing shrieks (hell, hyos.). Stiffness in the back 
of the neck ; inability to hold up the head. (Edematous swelling 
of the face (ai'S.). Sunken, half -closed eyes. Stinging, shoot- 
ing pains all over; hyperesthesia of the surface; soreness of the 
abdominal walls, Grating of the teeth. Scanty urination (aco.). 
Hurried, difficult respiration. Variable and intermittent pulse. 
Convulsions. 

Apocynum cann. — Hydrocephalus; open sutures; projecting 
forehead. Constant, involuntary movement of one arm and leg. 
Sight of one eye totally lost. Great irritability of the stomach 
with distressing vomiting. Suppression of urine (hyos.). 

Argentum nit. — Violent headache with vertigo. Digging, 
cutting pains from the occiput to the frontal protuberance. 



242 LECTUKES ON FEVEES. 

Painful fullness and heaviness in the head. Intolerance of 
light; clouds before the eyes; double vision (bell.). Soporous 
sleep, with constant murmuring. Pale, bluish, sunken face. 
Tender, easily bleeding gums (nit acid) . Irresistible desire for 
sweets (kali carb., opp. nit. acid). Violent cardialgia with 
griping and burning. Stools and urine pass unconsciously. Ir- 
regular, intermittent pulse . Tremulous weakness. Bluish-black 
eruption. Epileptiform convulsions. 

Arnica. — Stupid, apathetic state (plios. acid). Pressive 
headache, as if distended. Sticking pains in the temple and 
forehead. Great heat in the head with coldness of the body. 
Weakness of the cervical muscles; cervical vertebrae very sensi- 
tive to touch and pressure. Soreness in all the limbs (rhus) as 
if bruised. Great sinking of strength. Ecchymosed spots on 
the skin. 

Arsenicum alb. — Great restlessness, fear and anguish (aco- 
nite). Intense headache with vertigo and humming in the ears. 
Sensation as if the brain beat against the skull, during motion. 
Excessive photophobia. Stiffness of the nape of the neck and 
spine. Deathly color of the face. Grinding of the teeth during 
sleep (bell., hell.). Dryness of the mouth; tongue dry, brown 
and trembling (lach.). Difficult breathing, with great anguish; 
irregular, quick, weak pulse. Cramps in the calves. Epileptic 
convulsions. Petechia. Great weakness and prostration. 

Baptisia. — Frontal headache with pressure at the root of the 
nose (aconite). Bruised and painful feeling at the base of the 
brain and upper part of the spinal cord, worse on stooping. 
Stiffness and lameness of the cervical muscles. Restless, toss- 
ing about, rolling of the head f ron one side to another. Constant 
biting of the fingers, and moving of the feet, while unconscious.. 
Yertigo, with wandering pains in the limbs. Stiffness and lame- 
ness all over the body (arnica). Sensitiveness of the stomach 
to pressure (bry.); sinking gone feeling in the epigastrium (hyd., 
ign. ) . Urticarial eruption ( apis ) . 

Belladonna. — Yertigo, on sitting up or turning over in bed, 
with nausea and vomiting (bry., puis.). Alternate paleness and 
redness of the face (aco.). Stupefaction with head congestion, 
with dilated pupils ( hyos. ) ; double vision, rolling and squinting 
of the eyes. Great intolerance of light (opp. stram.). Violent 



LEADING INDICATIONS. 243 

throbbing pain extending from the neck into the head (aconite, 
glon.). Jerking headache, with inclination to bend the head 
backward. • Great soreness and stiffness of the neck. Shooting 
and gnawing pains in the spine and extremities. Drowsiness, 
yet inability to sleep ( lack. ). Eestless sleep with frequent start- 
ings (hyos., opium). Spasmodic distortions of the face and lips. 
Delirium, with grinding of the teeth and inclination to bite. 
Nausea with cutting, gnawing pain in the stomach. General 
hyperesthesia (coffea). Retention of urine or involuntary mic- 
turition. Coldness of the extremities with heat of the head. 
During dentition; and in young, full-blooded individuals. 

Bryonia. — Extremely irritable (cham.). Yertigo on sitting up 
in bed (aco., puis.). Splitting headache, worse from motion, 
and on opening the eyes, especially in the morning. Tearing 
pain in the right side of the head (bell, opp. aco.). Dark red 
face, suddenly changing color. Chewing motions during sleep. 
Child cries when taken up or moved. Drowsy sleep (rhus). 
Yivid, frightful dreams. Pressive pain in the occiput, drawing 
down into the neck, with stiffness. Pain in the back and limbs, 
as if bruised (am.). Loss of appetite; soreness of the stomach 
(bell). Tongue thickly coated white or else dry and brownish. 
Hasty, impetuous drinking and swallowing; desire for large 
quantities of water. Dysuria ; constipation. Dry, burning heat 
all over, especially in the head. 

Camphor. — Great anxiety and extreme restlessness (ars.). 
Yertigo with heaviness of the head, and constriction at the base 
of the brain. Throbbing in the cerebellum. Deadly paleness 
of the face. Severe chill with coldness of the face, tongue, lips 
and extremities. Icy coldness of the whole body. Sudden and 
great sinking of strength (ars. ). Yiolent cramps in the stomach 
and limbs. Suffocative dyspnoea. Small, weak, slow pulse. Ri- 
gidity of the limbs, clinching of the teeth, and retraction of the 
head. Tetanic spasms; epileptiform convulsions. 

Cannabis ind. — Yertigo on rising, with stunning pain in the 
occiput. Yiolent shocks through the brain. Involuntary move- 
ments of the head. Dilatation of the pupils with sensitiveness 
to light (bell. ). Extreme sensitiveness to noise. Paleness of the 
face. Suffocative dyspnoea. Irregular, feeble pulse. Hysteri- 



244 LECTUKES ON FEVERS. 

cal symptoms ; emprosthotonos with loss of consciousness. Hal- 
lucinations, 

Cantharis. — Anxious restlessness; great mental activity. Am- 
orous frenzy. Dysuria, or retention and suppression of urine. 
Violent burning and lacerating pain in the occiput. Stiffness o£ 
the neck, with tearing, lancinating pains extending up into the 
head. Oppression of the chest. Tearing in the limbs, relieved 
by rubbing. Over-sensitiveness of the whole body. Albumi- 
nous urine. 

Cicuta vir. — Vertigo, with jerking and twitching of the head. 
Severe occipital headache. Tonic spasms of the cervical mus- 
cles ; retraction of the head. Pupils dilated and insensible ( bell. ) - T . 
double vision (hyos.). Deafness. Grinding of the teeth (ema., 
ign. ). Jerking of the eyeballs and facial muscles; spasmodic 
distortion of the limbs; opisthotonos. Tonic spasms renewed 
from the slightest touch or noise. Convulsions with screaming.. 
Yiolent hiccough. Clenching of the teeth; inability to swallow. 
Dyspnoea. Gastralgia with vomiting and painful distension of 
the abdomen. Great agitation. 

Cimicifuga. — Intense pain in the head; brain feels too large 
(nux) Pain at the base of the brain and along the spine. Sen- 
sitiveness of the spine. Stiffness and retraction of the muscles 
of the neck and back. Intense aching pain in the eyeballs ( bry. ). 
"Redness of the fauces and palate. Circumscribed or diffused 
muscular soreness (am.). Great sensitiveness of the skim 
Profuse, general perspiration; creeping chills down the back. 
Alternate tonic and clonic spasms. Obstinate sleeplessness 
(coff, opium). Delirium resembling delirium tremens (digit);, 
sees cats and dogs, fear of death (aconite). 

Cocculus. — Vertigo with inclination to vomit on rising (bry.). 
Headache as if the eyes would be torn out. Violent pains in 
the forehead; convulsive trembling of the head. Pale, sallow,, 
bloated face. Hardness of hearing; noise in the ears like the 
rushing of waters (theridion). Swelling and induration of the 
sub-maxillary glands (mere). Violent cramp of the stomach 
(coloc). Spasmodic oppression of the chest; heavy, laborious 
respiration. Weakness of cervical muscles, with inability to 
support the head. Painful stiffness of the neck. Vivid, fearful 
dreams; fainting fits, hysterical and epileptiform convulsions. 



LEADING INDICATIONS. 215 

Miliary cutaneous eruptions. Trembling o£ all the limbs (ign.). 
Paralysis. 

Crotalus. — Intense headache; pain as from a blow on the oc- 
ciput. Delirium with open eyes. Extreme pallor of the face; 
anxiety and dyspnoea. Pain in the epigastrium; unquenchable 
thirst; faintness and vomiting. Pain in the extremities. Ecchy- 
moses; convulsions; paralysis. 

Cuprum. — Anguish with great restlessness and tossing about 
{ars. ). Afraid of falling; clings tightly to the nurse. Bruised 
feeling deep in the brain, and in the orbits on turning the eyes 
{gels., hell.). Convulsive motions of the eyes (gels.). Stupor, 
with twitching and jerking of the limbs. Coldness of the hands; 
bluish appearance of the fingers. Deep, sunken eyes, with blue 
rings around them. Spasmodic distortions of the face; the 
tongue is alternately protruded and withdrawn, with great rapid- 
ity. Violent intermittent contractive pains in the stomach; ten- 
derness of the abdomen. Painful contraction of the chest, 
especially after drinking; dyspnoea. Clonic spasms; epilepti- 
form convulsions. Herpetic eruption. In children during den- 
tition. 

Digitalis. — Great pressure and weight in the head; severe 
lancinating pains in the vertex and occiput. Stupor with dila- 
tation of the pupils. Stiffness of the cervical muscles. Tearing, 
cutting pains in the nape of the neck. Inability to support the 
head from weakness of the cervical muscles. Sleep with sudden, 
cracking noises in the head, frequent startings and dreams of 
falling. Deathly nausea, convulsive efforts at vomiting (tart. 
emet). "Vomiting with coldness; prostration; faintness: sensi- 
tiveness in the epigastrium. Extremely slow pulse (cann. inch), 
at times intermittent and irregular. Feeble, irregular, and la- 
bored action of the heart. Irregular, difficult and sighing res- 
piration. 

Gelsemium. — Brain feels as if bruised (cupr., hell). Dull- 
ness of the mental faculties (bapt.); feels as if intoxicated. 
Great exhaustion and drowsiness. Heat of the head with icy 
cold hands and feet. Feeling as of a band around the head, 
above the ears (mere). Convulsive movements during sleep. 
Itching of the head, face and neck. Paralysis of the eyelids. 
Double vision; dilated pupils. Nausea and vomiting, with weak, 



246 LECTURES ON FEVERS. 

scarcely perceptible pulse. Feeble, labored respiration. Trem- 
bling and complete loss of muscular power. Inability to direct 
the movements of the limbs. Neuralgic and rheumatic pains in 
the extremities (bry. } cim., rhus). Yellowish-white coating on 
the tongue; dysphagia. Sweating relieves (opp. mere). In 
children and nervous people. 

(jlonoine. — Congestion of the head with a sense of expansion. 
Fullness and pulsation in the head (bell). Undulating, wave- 
like motion in the brain (hyos. ). Pain along the whole length of 
the spine. Pains ascend from the chest and neck to the occiput.. 
Optical illusions; eyes injected and rolled upwards; pupils di- 
lated (bell). Blindness with faintness and nausea. Bluish 
pallor under the eyes. Deafness with ringing in the ears. Al- 
ternating redness and paleness of the face. Nausea and vomit- 
ing with headache. Pulse mostly accelerated; often rises and 
falls, alternately. Sudden spasms. 

Hellelborns. — Vertigo. Stupefaction with sensation of sore- 
ness in the back part of the head, as if bruised. Boring of 
head in pillow (apis). Face, pale and oedematous. Frequent 
rubbing of the nose (cina). Constant chewing motions (bry.); 
grating of the teeth (hyos,), Drinks cold water hurriedly; rolls 
the tongue from side to side. Automatic motion of the arm and 
leg on one side. Convulsive movements of the muscles (cupr*)* 
Soporous sleep with screaming and starting. Nausea with vom- 
iting of green mucus (ipecac). Urine scanty and dark, with a 
sediment like coffee-grounds. Bapicl, small, tremulous pulse. 
Hydrocephalus. In scrofulous children; during dentition. 

Hyoscyamiis. — Pressive, stupefying headache. Undulating 
sensation in the brain (glon.)< Violent pains in the head alter- 
nating with pains m the nape of the neck. Pressure in the 
vertex and drawing in the nape of the neck, when turning the 
head. Sensation as if the brain were shaken and loose (bell). 
Startings from fright (gels.); grinding of teeth (hell). Dim- 
ness of vision, paralysis of the tongue; constriction of the 
throat. Inability to swallow fluids (bell, siram.). Involuntary 
stools and urine, or else retention. Stiffness of the cervical 
muscles. Convulsive jerks of muscles (bell). Stiffness of the 
arms and legs; jerking of the hands and feet. Kigiclity. Spasms 
of the chest, with arrest of breathing. Small, quick, intermit- 



LEADING INDICATIONS. 217 

tent pulse. Cutaneous hyperesthesia. Epileptiform convulsions. 

Ignatia. — Changeable disposition; alternate gaiety and tears 
(Jiyos.). Pressing headache, as from a nail, from within to with- 
out. Jerking headache, aggravated by raising the eyes. Con- 
vulsive movements of the eyes and lids. Twitching of the 
muscles of the face. Spasmodic constriction of the chest; fre- 
quent sighing. Throbbing in the abdomen (aloes). Stiffness of 
the nape of the neck (kali carb., lack.). Convulsive jerking of 
the arms and legs (sir am. ). Over-sensitiveness to pain (coffea); 
hysteria. Yiolent pain in small spots, only discovered on touch- 
ing them. Convulsions. During dentition; or after fright or 
grief. 

Lacliesis. — Pressive headache, over the eyes and in the occi- 
put. Pains extend from the head to the neck arid shoulders; 
heaviness in the occiput with vertigo. Stiffness of the nape of 
the neck (rhus). Pricking, pulsating, tearing pains. Cramp- 
like pain in the precordial region, with irregular action of the 
heart. Oppression of the chest. Difficult speech; tongue trem- 
bles when protruded, or catches behind the teeth. Solids swal- 
low better than liquids. Cannot bear the clothing tight around 
the waist (opp. nit acid). Miliary eruption. 

Laurocerasus. — Stupefying pain in the head; brain feels as 
if loose. Twitching and convulsions of the facial muscles 
(cicida). Difficult deglutition (siram.). Lock-jaw (hyos.). 
Spasmodic oppression of the chest. Irregular beating of the 
heart, with slow pulse (dig.). Stiffness in the nape of the neck 
and small of the back. Stinging, tearing in the extremities. 
Rapid sinking of the vital forces (camphor, verat). 

Lycopodium. — Dread of being alone. Stupefying headache, 
extending down the neck, worse from 4 to 8 p. m. Pressive 
headache in the vertex (nux). Stiffness of the neck; tensive 
pain in the neck and occiput. Drowsiness, with loud screams 
during sleep; ill-humor after sleep. Over-sensitiveness of hear- 
ing with roaring in the ears (cann. ind.). Over-sensitive smell; 
fan-like motion of the nostrils. Pendulum-like motion of the 
tongue, which is swollen. Sinking of the lower jaw (opium, mix, 
mur. acid). Yellowish-gray color of the face (ars.); blue rings 
around the eyes. Tension in the abdomen and chest as from a 
hoop (cact.)o Burning pains between the shoulders (phos.). 



248 LECTURES ON FEVERS. 

Drawing, tearing in the limbs at night (mere). Numbness and 
twitching through the body and limbs. Pneumonic complica- 
tions (phos.), 

Nux vom. — Drawing, tearing, jerking pains in the head, from 
the orbit to the occiput. Shocks, starting suddenly from one 
portion of the brain, with numbness and drawing in the limbs. 
Sensation as from a bruise in the back of the head. Over-sen- 
sitiveness to external impressions. Heaviness and stiffness in 
the neck. Tearing pain in the nape of the neck and back (puis.). 
Stitches through the body in jerks. Paleness of the face; 
twitching of the facial muscles. Straining to vomit, first water, 
then food (opp. ipecac). Opisthotonos with unconsciousness. 
Convulsions renewed by the slightest touch (stram.). 

Opium. — Stupefaction with half -open eyes; deep, slow, snor- 
ing respiration. Stupid sleeplessness with frightful dreams. 
The occiput feels as heavy as lead; the head falls back, con- 
stantly. The eyes are fixed and half -closed (bell.); pupils con- 
tracted (hyos., physostigma) or dilated, insensible to light. 
Dark-red, bloated face; relaxation of the muscles, with twitch- 
ing of the lips and flapping of the cheeks. Lock-jaw. Opistho- 
tonos (nux). Abdomen hard, distended, and sensitive to the 
touch. Pulse variable; very quick or very slow. Dyspnoea. 
Spasmodic jerkings, and numbness of the limbs. Heat with 
sweat; sleep with sweat; worse while perspiring (mere, opp. 
gels. ) ; bed feels so hot, cannot lie on it. Convulsions, with loud 
screams on entering the fit. 

Oxalic acid. — Pressing in small spots in the head. Pale, 
sunken face. Dryness in the throat with difficult deglutition. 
Stomach very sensitive to pressure. Oppression of the chest. 
Pain in the back, between the shoulders, extending to the loins. 
Coldness and numbness of the hands; stiffness and paralysis of 
the lower extremities. Pains appear periodically. Thinking of 
the symptoms aggravates them (opp. camphor). 

Phosphorus. — Stupefying headache, with acuteness of smell 
(bell., lye). Burning and stinging pains and pulsations com- 
mencing in the occiput. Stiffness in the nape of the neck, sen- 
sitiveness of the spine; back pains as if broken. Difficulty of 
hearing, especially of the human voice; contracted pupils (opi- 



LEADING INDICATIONS. 249 

um, physos. ). Face bloated or cadaverous-looking. Formication 
and tearing in the limbs. Soreness of the abdomen and stomach 
to touch. Spasmodic contractions of: the chest (moschus). 
Dyspnoea with inability for exertion. Pneumonic complications 
(lye). Extensive petechia or hemorrhages. After over-doses of 
camphor. 

Pkysostigma. — Contraction of the pupils (opp. bell). Obsti- 
nate constipation, with flatulent distension of abdomen. Pain 
in the stomach immediately after eating. Tetanic spasms with 
irregular, tumultuous action of the heart. Epileptiform con- 
vulsions. 

Plumbum. — Heaviness in the head, especially in the cerebel- 
lum. Sudden deafness. Twitching and jerking in the limbs. 
Sharp, neuralgic pains in the lower limbs occurring in parox- 
ysms; hyperesthesia. Paralytic weakness in the limbs ; wasting 
of the muscles of paralyzed parts. 

Rhus tox. — Stupefaction; vertigo when rising from the bed 
(bry., gels. ). Anxiety with great restlessness (ars.). Disturbed 
sleep with vivid, frightful dreams. Fullness and bruised pain 
in the head extending to the ears; aching in the occiput. Hem- 
orrhage from the ears and nose. Swelling and hardness of the 
salivary glands. Dryness of the mouth with much thirst (nit. 
acid). Thirst for cold water or cold milk. Bed, dry and cracked 
tongue (bapt., bell). Various eruptions; red rash all over the 
body; eczema on the face (lye, mere). Short, dry cough from 
tickling in the bronchi (rumex). Sensation of weakness and 
trembling in the heart (bell, spig.). Pains in the shoulders and 
back as if strained. Tearing tensive pains, with stiffness of 
muscles and joints. 

Solanum . — Terrific headache, as if the head would split. Pav- 
ing delirium; convulsions with moaning and coma. Violent 
subsultus tendinum; tetanic rigidity of the whole body. Con- 
traction of the pupils; slowness of the pulse. Neck feels stiff 
and sore, as if bruised (aim.). Weakness and bruised feeling 
in the back and limbs (rhus, rhod.). Stiffness and convulsions 
excited by tk<.: least touch. 

Spongia. — Heat in the head with redness of the face (bell). 
Pressing, knocking, pulsating pain in the forehead. Dull head- 



250 LECTUEES ON FEYEKS. 

ache in the right side of the brain, better when lying in the 
horizontal position. Stupid slumber; frequent waking with a 
start. Painful stiffness of the muscles of the neck and throat. 
Throwing the head backwards with tension in the neck. Double 
vision; staring eyes. Dyspnoea and great weakness in the chest. 
Full, hard, frequent pulse. 

Stramonium. — Convulsive movements of the head, mostly to 
the right side; head bent forward instead of back. Head and 
face hot; limbs cold. Furious delirium (bell.). Indifference to 
persons or things (phos. acid) ; calls for persons who are present, 
but does not know them. Stammering or speechlessness. 
Screaming as if frightened on waking (bell). Conjunctivae in- 
jected; pupils dilated (hell, hyos.); transient, total blindness. 
Bright light and glistening objects cause convulsions. Great 
dryness of the mouth and fauces. Dysphagia (bell., hyos.). 
Trembling and convulsive movements of the limbs, Suppres- 
sion of all secretions and excretions. Intense scarlet rash over 
the whole body (bell., rhus). Suppressed miliary eruptions. 

Sulphur. — Heaviness, fullness and pressure in the forehead. 
Pain as if the brain were beating against the skull (mix, spig.). 
Scalp painfully sensitive to the touch (cinch.). Sweat on the 
head of a musk-like odor. Pale, distorted features. Ulceration 
of the margins of the lids (mere). Pustules and ulcers on 
and around the cornea (lach., sil.). Sour smell from the 
mouth, especially in the morning. Hardness of hearing (caust); 
ringing and roaring in the ears (cinch.). Drawing, tension and 
stitches in the nape of the neck. Drawing, tearing pains in 
the limbs. Cramps in the calves of the legs and soles of the 
feet, especially at night (silicea). Turbid urine {lach.) with 
red sediment. 

Tarantula. — Intense headache, deep in the brain, aggravated 
by touch, with restlessness and anguish. Sensation as of cold 
water being poured (dropped, cann. sat.) on the head. Pain in 
the occiput as if striking it with a hammer. Pricking itching 
sensations over the whole body. Convulsive trembling of the 
body. 

Yeratrum alb. — Violent headache with delirium; or uncon- 
sciousness. Rolling of the head from side to side, with short 
screams; boring the head in the pillow (apis). Convulsive 



LEADING INDICATIONS. 251 

shocks and vomiting as soon as head is raised. Spasms with 
convulsive motions of the limbs. Stiffness of the neck. Pale> 
cold, sunken, pointed face (ars., camphor). Cold sweat on the 
forehead. Yiolent vomiting, with nausea and great exhaustion. 
Tongue cold (carbo veg.); or red and swollen (bell, rhus). 
Cramps in the calves (sulph.). Tingling and coldness of the 
limbs. Icy coldness of the hands and feet. Feeble, irregular, 
intermittent pulse. Sudden sinking of strength (ars., camphor). 

Teratrum vir. — Severe frontal headache with vomiting. Yer- 
tigo and headache with dilated pupils and dimness of vision. 
Headache proceeding from the nape of the neck (sang.). Trem- 
bling as if frightened and on the verge of spasms. Boiling of 
the head and eyes. Opisthotonos. Sudden spasms with nausea, 
vomiting and utter prostration. Constant, severe, aching pain 
in the neck and shoulders. Convulsive twitchings of the mus- 
cles of the face (cicuta, gels.). Face flushed (bell); or pale, 
and covered with a cold perspiration (verat alb.). Coldness of 
the whole body (verat alb.). Dryness of the mouth and lips. 
Red streaks in the middle of the tongue; yellow edges. Small- 
est quantity of food causes vomiting. Spasms of the oesophagus ; 
painful, almost constant hiccough. Oppression of the chest. 
Galvanic-like shocks in the extremities. Paralysis. In plethoric 
individuals. 

Zincum. — Retarded convalescence, with weakness of memory 
{anac, mix). Frequent attacks of vertigo. Pressure in small 
spots on the head. Stiffness and pain in the cervical and upper 
dorsal muscles. Bruised pain in the small of the back. Alter- 
nate paleness and redness of the face (aconite). Earache. Dry- 
ness and constriction in the throat with accumulation of mucus. 
Gagging and vomiting with ravenous hunger and obstinate con- 
stipation. Scanty, turbid urine as if mixed with clay. Dysuria. 
Involuntary urination while coughing or sneezing (caust). 
Twitching and jerking through the whole body during sleep. 
Drawing, tearing pains in the limbs. Stiffness of the joints with 
transverse lancinating pains above the joints. Cannot keep the 
feet still. Exhaustion of nerve force. Profuse sweats. 

HYGIENIC AND DIETETIC TEEATMENT. 

The general management of cerebro-spinal fever may be 
summed up in a few words. The sick room should be darkened 



252 LECTUBES ON FEVEBS. 

and well ventilated, and the strictest quietude observed. A hot 
mustard foot bath or a general hot-bath (100.5° Fahr. to 102° 
Fahr.) should be employed as early as possible. Hot water 
may be applied by a sponge passed over the spine every two 
or three hours. Or a compress wrung out of hot water may be 
kept constantly applied to the nape of the neck. Continuous 
heat is employed in preference to cold, as the tendency to early 
depression is frequently counteracted by it. Stimulation with 
brandy or whisky must be resorted to whenever symptoms of 
depression of the nervous system show themselves. The amount 
of stimulation necessary will be regulated as in other fevers by 
the pulse, and first sound of the heart. 

The diet should consist of milk, meat-juice, broths, light soups, 
and light farinaceous foods. It should be given at intervals of 
two hours during the day. and three hours during the night, ex- 
cept when resting quietly. Solid food may be allowed as soon 
as the patient is able to digest it. 

When spasms or irritability of the stomach render the admin- 
istration of food and medicines by the mouth impossible, nutri- 
tious enemas should be employed, and the medicine administered 
hypodermatically (page 98.). 

In cases attended with great prostration, as there is danger of 
syncope, the patient should be kept constantly in the recumbent 
posture. 



LECTUEE XVII. 

Influenza. 

Definition. — Influenza is a miasmatic-contagious disease, of 
from three to ten days' duration, due to an unknown morbific 
agent, and occurring only in wide-spread epidemics. It is char- 
acterized by suddenness of onset; by great and early prostration; 
and by the development of general catarrhal symptoms. Usu- 
ally there is intense frontal headache, coryza, sore throat, a 
tickling cough, dyspnoea, pains in the back and limbs, fever of 
varying intensity, and great nervous depression. At times there 
is more or less severe catarrh of the gastroenteric mucous mem- 
brane with hepatic disturbance. Inflammatory affections of the 
lungs are not rare complications. The disease is very rarely 
fatal, except in advanced life. When death takes place, it is 
generally the result of complications. Relapses are not uncom- 
mon. 

Synonyms. — Epidemic catarrhal fever. Epidemic catarrh. 
La Grippe. 

History. — Although influenza is a disease which is supposed 
to have prevailed from remote antiquity, it has been clearly re- 
corded only since the beginning of the fourteenth century. In 
1311 and 1103 a very fatal epidemic prevailed in France. In 
1510 an epidemic, starting in Malta, spread in a northwesterly 
direction, and traversed the whole of Europe. A rapidly spread- 
ing epidemic started in Asia in 1557, and extending to Europe 
and America, encircled the globe. In 1580 a great epidemic 
taking a northwesterly course, overran Asia, Africa and Europe. 
During the seventeenth century several epidemics are recorded 

(253.) 



254 LECf UEES ON FEVEBS. 

as having occurred throughout Europe, Great Britain and Amer- 
ica. A wide-spread epidemic swept over Europe in 1729 and 
1730. Two years later a mild and slowly-spreading epidemic 
started in Saxony, traveled in a northwesterly direction until it 
reached the British Isles, and there dividing and passing in 
southward, westward and southeasterly directions, it traversed 
the American continent, the West Indies and eastern Europe. 
Several widely-extended epidemics prevailed in Europe, Amer- 
ica and the West Indies between the years 1737 and 1780. A 
remarkable epidemic starting in Asia in 1782 traveled westward 
through Europe, and even attacked the crews of ships upon the 
high seas. Children were relatively exempt from seizure during 
this epidemic. Numerous recurring outbreaks occurred in Eu- 
rope and America from 1788 to 1827. In 1830 the disease began 
in China, and by a series of wide and rapidly spreading epidem- 
ics, in a tour which occupied two years, again encircled the 
world. In 1837 it reappeared in Russia, and again spread over 
Europe. Erom this time on till 1850-51 numerous epidemics 
occurred. In the United States the epidemic of 1843 was re- 
markable for the greatness of its extent. Since 1850 all epidem- 
ics of influenza have run a comparatively mild course. Extensive 
but mild epidemics prevailed as epizootics among domestic ani- 
mals throughout the United States and Canada, in 1872, 1880 
and 1882. 

Etiology. — The causes of influenza are of two kinds, predis- 
posing and exciting. 

1. The Predisposing Causes. — Climate has no direct influence 
upon the extent of the prevalence of the disease. Its course is 
not cyclical nor is it in any way connected with known atmos- 
pheric conditions. It appears in every latitude, and prevails 
alike in hot and dry, or cold and wet seasons. 

Age exerts little influence as a predisposing cause. Infirm 
and aged persons are supposed to be most susceptible. In some 
epidemics children are almost exempt. 

Sex in itself has no influence upon the course of the disease, 
although statistics show that in most epidemics females are the 
first to be attacked. 

Occupation does not in any way predispose to influenza. 

The mode of life of the individual exerts little influence. 



CLINICAL HISTOEY. 255 

Overcrowded or illy ventilated habitations are supposed to favor 
the greater prevalence of the disease. 

Previous attacks afford no protection. 

Mpidemics do not follow the great lines of human travel, but 
extend over vast areas, usually in a direction from the east or 
northeast toward the west and south. At times they radiate in 
different directions from various centers. The rate of progress 
of the epidemic influence may be either slow or rapid. When 
it enters a locality, it prevails, as a rule, from one to two months. 

2. The Exciting Cause. — The nature and origin of the mor- 
bific agent of influenza remains as yet unknown. It is generally 
supposed to be a living miasm having an independent existence, 
and capable, to a slight extent, of being reproduced in or about 
the human body, and of being transmitted by the air, or by the 
persons or clothing of those affected. The period of incubation 
varies from a few hours to several days. 

Clinical History.— The course of an attack of influenza, which 
may be either mild or severe, will depend partly upon the char- 
acter of the epidemic, partly upon the activity and quantity of 
the morbific agent, and partly upon the power of resistance of 
the patient. In mild cases there is a general feeling of malaise, 
followed by a sub-febrile state attended with nervous prostration 
and slight catarrhal symptoms. 

In severe cases the onset of the attack is usually abrupt. A 
chill or chilliness alternating with heat marks the invasion of 
the disease. The fever, which soon follows, may be either mod- 
erate or of high grade, and displays a tendency to morning re- 
missions. Intense frontal headache, with pains in the orbits, in 
the region of the antrum of Highmore, and the Eustachian tube, 
and at the root of the nose, appears early. Sneezing, swelling 
and redness of the eyelids and nostrils, a watery discharge from 
the nose, lachrymation and loss of the sense of smell, rapidly 
supervene. The throat becomes sore, and there is loss of taste 
and appetite. A dry, tickling paroxysmal cough appears, at- 
tended by more or less hoarseness, chest pain, and dyspnoea. 
The pulse is full and but slightly increased in frequency. There 
is restlessness, pain in the extremities and great nervous depres- 
sion. Cutaneous hyperesthesia occasionally occurs. At times 
symptoms of catarrhal disturbance of the gastro-intestinal tract 



256 LECTUKES ON FEVERS. 

predominate. Exceptionally the disease attacks the mucous, 
surfaces of the head, chest and abdomen. 

The continuance of the fever is usually of short duration. At 
the end of four or five days defervescence sets in, and the tem- 
perature returns, at times gradually, oftener rapidly, to the 
standard of health. When complications appear the fever may 
continue ten or twelve days. The defervescence is often marked 
by copious perspiration, an increased now of urine depositing 
urates, or a spontaneous flux from the bowels. The catarrhal 
symptoms usually disappear within two or three days after def- 
ervescence, while the cough and expectoration may continue for 
an indefinite period. 

Inflammatory lung complications, such as capillary bronchitis 
or catarrhal pneumonia, occur in from five to ten per cent of the 
cases. They occur oftener in old persons, and in those of feeble, 
delicate constitutions, Kecrudescences of fading neuralgias are 
not uncommon. 

Duration. — The mildest form of influenza lasts two or three 
days. The severe type runs its course in from four to ten days. 
When complications exist, weeks may elapse before recovery 
takes place. 

ANALYSIS OF CHART. 

The Temperature. — The fever is extremely variable. It 
ranges from 100° or 102° Fahr. in moderate cases, to 104° Fahr. 
in the more severe forms. It is, as a rule, higher at night than 
in the daytime. In the aged and infirm it is apt to run an ady- 
namic course. 

The Pulse. — The pulse is as changeable as the temperature. 
It is moderately increased in frequency. 

The Nervous System. — In most epidemics great and early 
prostration is a marked symptom. Headache appears early, and 
is persistent. It is commonly frontal, sometimes general, and is 
severe in character. It usually increases in severity towards 
evening. Deep-seated pains, due to the general hyperemia and 
catarrhal inflammation of the mucous lining of the cavities of 
the head, are referred to the frontal sinuses, antrum of High- 
more, Eustachian tube and middle ear. Soreness and a bruised 
feeling in the limbs, and dull, tearing pains in the joints are 
almost constant symptoms; while stitches in the chest are not 



ANALYSIS OF CHAKT. 

JHAKT XI.— Influenza. 



257 



Nature: 


Epidemic. M iasmatic-contagious. 


Duration: 


Two to ten Days. 


Initial Symptom: 


A chill, or chilliness alternating with heat. 


Temperature : 


102 c to 104* Fahr. Remittent and variable. 


Pulse : 


Variable. Moderately accelerated. 


Nose : 


Sneezing. Abundant discharge. Redness. Epistaxis. 


Eyes: 


Lachrymation. Eyelids swollen and reddened. 


Chest: 


Paroxysmal racking cough. Myalgia. Dyspnoea. 


Nervous System : 


Frontal headache. Sleeplessness. Mild delirium. Severe pains in 
the back and limbs. 


Throat : 


Sore throat. Pharyngitis. Tonsilitis. Hoarseness. 


Digestive Tract : 


Anorexia. Loss of taste. Coated tongue. Constipation or diarrhea 


Urine: 


Diminished. Deposits urates. 


CutaneousSurface 


Hot and dry. Hyperesthesia. Sudamina. Herpes labialis. 


Complications: 


Capillary bronchitis. Catarrhal pneumonia. Parotitis. 


Prognosis: 


Favorable, except in very young or very old persons. 


Relapses: 


Not uncommon. 


Recurrence. 


A previous attack affords no protection. 


Incubation: 


From a few hours to two or three weeks. 



uncommon. In severe cases the patients are generally restless 
and anxious, and there is marked insomnia. Mild delirium fre- 
quently occurs,but is mostly transitory. In the worst types there 
may be cramps, tremors and subsultus tendinum. Old neural- 
gias sometimes reappear during convalescence. 

The Respiratory Tract.— The mucous membrane of the 
respiratory tract is more or less hypersemic; the discharge from 



258 LECTURES ON FEVERS. 

the nostrils is abundant; the lachrymation and the sneezing are 
strongly marked. The sore throat is attended by more or less 
difficulty in swallowing and hoarseness. Troublesome laryngitis 
and chronic bronchitis sometimes remain as sequels. Cough, 
which is almost always a prominent symptom, is frequent and 
distressing in character. Occasionally it becomes spasmodic, 
simulating whooping cough. It is generally worse towards night. 
It is apt to be dry at the outset, but is attended by more or less 
muco-serous or muco-purulent expectoration as the disease pro- 
gresses. Dyspnoea is a not unfrequent symptom, and may be 
either of nervous origin from disturbance of the vagus, or due 
to existing complications. 

Capillary bronchitis and catarrhal pneumonia are not uncom- 
mon complications. The latter often appears insidiously about 
the fourth or fifth day. Lobar pneumonia, as manifested by 
dullness, crepitus, bronchial respiration and rusty sputa, some- 
times occurs as a late complication. Pleurisy, except as associ- 
ated with lobar pneumonia, is rarely met with; at times it is 
associated with pericarditis. Localized collapse of the lung 
often occurs. 

The Digestive Tract. — The thirst, loss of appetite, and im- 
paired taste are due to the catarrhal state. Nausea and vomiting 
sometimes occur. Swelling of the parotid glands is occasionally 
present. The tongue is usually pasty, and coated with a whitish 
or yellowish-white fur. Tenderness in the epigastrium and con- 
stipation are present in a large proportion of cases. In some 
forms an intestinal catarrh gives rise to more or less diarrhea 
and colic pain. 

The Urine. — The urine presents the characteristics of febrile 
urine in general. Its amount varies with the quantity of fluids 
ingested. As a rule, it is diminished; at times it becomes sup- 
pressed. It is frequently cloudy, and contains an abundance of 
urates towards the close of the disease. 

The Cutaneous Surface. — At the outset of the attack, the 
skin is hot and dry; later on, sweating frequently occurs. Co- 
pious acid sweats are not uncommon during defervescence. 
Plentiful crops of sudamina frequently appear as a result of the 
abundant perspiration. An outbreak of herpes occasionally oc- 



DIFFERENTIAL DIAGNOSIS. 259 

•curs, and is a favorable indication. The general sensibility of 
the surface is not infrequently increased. 

Morbid Anatomy. — The - anatomical lesions of influenza are 
mainly restricted to the upper air-passages and bronchial tubes, 
and consist of congestion and catarrhal swelling of the mucous 
lining. The bronchial glands occasionally become enlarged. 
When complications exist, changes of lung tissue marked by 
hyperaeniia, oedema, hypostatic congestion, splenization or hepat- 
ization, are observed. 

Differential Diagnosis. — Although there are no special diag- 
nostic signs that can be regarded as characteristic of influenza, 
its discrimination is, under ordinary circumstances, unattended 
with difficulty. The march of the epidemic, the large number 
of persons attacked, the prominence of nervous symptoms, the 
early prostration, and the annoying cough disproportionately 
severe in comparison with the physical signs, are distinguish- 
ing symptoms. 

It may be confounded with simple catarrh, acute bronchitis, 
and typhoid fever. 

Simple catarrhs are due to sudden changes in the weather, 
and usually appear as spring approaches, while influenza epi- 
demics occur without regard to the seasons. 

Acute bronchitis is a bilateral bronchial affection, characterized 
by a harsh cough with frothy, sometimes bloody, expectoration. 
Its physical signs are dry, sonorous or sibilant rales, succeeded 
after twenty-four or forty-eight hours by large and small, moist, 
mucous rales. When there is considerable secretion,bronchial 
fremitus is marked. 

Typhoid fever differs from influenza, in having a typical tem- 
perature curve, a rapid pulse, a rose eruption, and pea-soup dis- 
charges. 

Prognosis. — The prognosis varies in different epidemics, but 
is generally favorable except at the extremes of life. Yarious 
affections of the respiratory organs often appear as sequels. 
When death results it is mostly from complications. 

Treatment, — Prophylaxis. — During the visitation of an in- 
fluenza epidemic, the weak and the aged, and such as are en- 
feebled by chronic maladies, should be well taken care of. All 
susceptible individuals should remain indoors after sunset. The 



260 LECTUEES ON FEVERS. 

iodide of arsenicum 3rd trii, arum drac. 1st trii, or sticta 1st. 
dil., may be administered morning and evening as a preventive. 

Principal Remedies. — Camphor may be of service during the 
first few hours of an epidemic. Gelsemium will be needed when 
the febrile symptoms are of a remittent character, chills run 
along the back, the face is flushed, the eyes are suffused, and 
there is a thin, watery, non-irritating discharge from the nostrils. 
Arsenicum iodide, when there are alternate chills and heat, 
and when the discharges from the nostrils are watery, irritating 
and corrosive in character. Arsenicum alb., when the disease is 
located principally in the nose and larynx. The discharge from 
the nostrils is copious, watery and excoriating. There is obsti- 
nate ophthalmia, headache, burning in the frontal sinuses, larynx 
and trachea, and great prostration. Mercurius vivus at the out- 
set, frequent sneezing with profuse coryza, short, dry, racking 
night cough, with painfulness of the whole thorax, and after- 
wards frothy, mucous expectoration. It is also of service when 
there is severe gastric catarrh and diarrhea. Bryonia in old 
people and when the affection is seated mostly in the large bron- 
chi. There is distressing frontal headache, dry nasal catarrh,, 
continuous, irritating, violent cough, worse in the daytime, fre- 
quently causing retching, pains in the chest, soreness and shoot- 
ing, tearing pains on motion all over the body. Potassium iodide 
for painful violent sneezing with profuse, acrid, watery discharge, 
and lachrymation; and when there is a troublesome irritating 
cough, with oppression of breathing, and gray, sweetish- salt 
expectoration. Sticta for violent sneezing, with intense head- 
ache and conjunctivitis. And when the attacks are preceded by 
rheumatic pains and swelling of the small joints. Eryngium 
aquaticum for raw, smarting, burning sensations in the throat 
and larynx with constant irritating cough, and tenacious, yellow 
mucous expectoration. Euphorbium for frontal headache, watery 
discharge from eyes and nose, with burning and smarting pains 
in the back and limbs. Eupatorium perf. when the bone pains 
are excessive and there is intense bronchial irritation with severe 
cough. Rhus tox., at the beginning when there is lameness or 
soreness in the extremities as if bruised; or a short, dry, night 
cough aggravated by motion or currents of cold air. Wyethia 
when there is dryness in the pharynx, with burning and dryness 
in the epiglottis, and a dry, hacking cough. Senecio for catarrhal 



LEADING INDICATIONS. 261 

affections of the stomach and bowels, mucous coughs, or ob- 
structed menstruation. Carduus when hepatic symptoms are 
marked. Arum drac. when laryngeal symptoms predominate. 
Verat alb. when prostration is extreme. Sabadilla for excessive 
sneezing. Euphrasia or allium cepd for excessive lachrymation. 
Hyoscy amies for spasmodic cough, worse on lying down. Co- 
nium, after gelsemium, if the cough is relieved by the expecto- 
ration of a mass of frothy mucus with yellow nucleus. Tartar 
emet., kalibich. and nit 'rate of sangainaria for the bronchitis. 
Phosphorus when the disease is localized in the larynx or there 
is a tendency to pneumonia. Sulphur, phos. or silphium for 
non-tubercular pulmonary affections occurring as sequels. 

Leading Indications. — The guiding symptoms for the differ- 
ent remedies may be compiled as follows: 

Aconite. — Chilliness with burning heat in the head and face. 
High febrile excitement with full, hard, quick pulse. Anxiety 
and great restlessness. Distressing pressure at the root of the 
nose {mere. ). Short, dry, racking cough from tickling in the 
larynx, with or without oppression. Stitches in the chest (bry.). 
Internal shuddering with dry, hot skin and tendency to uncover. 
Sudden suppression of perspiration. Coryza with sneezing 
(sang.). After exposure to cold west winds (hepar). 

Allium cepa. — Violent sneezing with profuse acrid coryza 
(mere. ). Smarting of the eyes with profuse bland lachrymation 
(euph.). Headache with coryza, upon entering a warm room 
(puis.). Hacking cough from inhaling cold air (ars.). 

Ammonium carl). — Fluent coryza, with stoppage of the nose. 
Burning water runs from the nose (mere. cor.). Roughness and 
.scraping in the throat (caust). Cough worse after midnight. 
In delicate women. 

Ammonium mur. — Frequent sneezing. Watery, acrid dis- 
charge from the nose, corroding the lips (mere. cor.). Loss of 
smell. Loss of appetite. Hoarseness and burning in the larynx. 

Arsenicum alb. — Frequent sneezing, with profuse watery dis- 
charge from the nose, corroding the lips and making the upper 
lip sore (arum., mere. cor.). Profuse lachrymation and burning 
in the eyes (aconite). Inflammation of the eyes; photophobia. 
Extreme debility with dyspnoea on lying down. Great thirst 



262 LECTURES ON FEVERS. 

with chilliness after drinking. Desire for acids, cold water or 
spirits. Spasmodic cough with desire to vomit; worse after 
midnight, after eating and on lying down. Cough with frothy, 
tough expectoration. When coughing a pain extends from the 
lumbar region dowii into the thighs. Diarrhea; the evacuations 
excoriate the anus {mere). Great restlessness and anxiety, 
especially at night. 

Arsenicum iodide. — Chilliness alternating with flashes of 
heat. Sneezing with irritating, corrosive discharge. Short, dry 
cough with tightness in the chest; worse in the open air (opp. 
puis.). Puffiness of the lower lids and face {apis, euphorb.). 

Arum drac. — Dryness and stiffness of the eyelids with smart- 
ing and burning. Shooting pains in the ears, with accumulation 
of mucus in the Eustachian tube. Dryness and smarting in the 
throat, with hawking and constant coughing [sang. nit.). Rat- 
tling of mucus in the larynx at every expiration, with cough. 
Paroxysms of dyspnoea at night, with aching in the chest. Great 
muscular weakness and prostration. 

Badiaga. — Spasmodic cough, with sneezing and lachrymation. 
Painfulness of the left eyeball. Pressing of the hands upon the 
head while coughing. The cough is loose in the forenoon but 
tight towards evening and at night. Scrofulous inflammation of 
the eyes, with induration of the Meibomian glands. 

Belladonna. — Dryness of the nose, with dull frontal headache. 
Prequent sneezing; sore throat and hoarseness. Throbbing 
headache, worse from motion and coughing. Great dryness 
of the mouth and throat. Swelling and tension of the upper 
lip {cede). Hot skin, with inclination to perspire. Drowsiness 
with starting during sleep {ars., mere). Barking cough {dros., 
verbascam). Dry, spasmodic, or hollow hoarse cough, worse at 
night {dros.). 

Bryonia. — Headache in the morning, when first opening the 
eyes. Dry coryza with inflamed and ulcerated nostrils. Great 
irritability. Pain in all the limbs, aggravated by motion. Dry 
cough with pain and soreness in the pit of the stomach. Urina- 
tion when coughing {cina). Tight cough, worse through the 
day, from entering a warm room and from motion. Desire te- 
lle down and remain quiet. 



LEADING INDICATIONS. 263 

Calcarea carb. — Frequent sneezing with coryza. Painless, 
morning hoarseness (canst.). Chest painful to the touch, and 
on inspiration. Loose cough with rattling of mucus in the chest. 
Night cough. Profuse head sweat when sleeping. Weight in 
the stomach soon after eating. In scrofulous persons and teeth- 
ing children. 

Carbo veg. — Fluent coryza, with evening hoarseness. Burn- 
ing in the eyes and profuse lachrymation (mere. ). Beating or 
pulsating headache (bell.). Painful stitches through the head 
when coughing (bry.). Cough, at long intervals, aggravated by 
breathing cold air. Soreness of the chest, and heat of the body 
when coughing. Profuse and constant flow of stringy saliva. 

Causticum. — Paroxysmal cough with pain in the hips and in- 
voluntary urination (bry., eina). Morning hoarseness; loud 
rales when coughing. Violent, hollow, dry cough, worse at night 
on getting into bed; better in bed, and from drinking cold water. 
Pain in the malar bones; stiffness and lameness in the jaws. 
Backache, especially in the coccyx. Much thirst for cold drinks. 
Aversion to sweet things; fresh meat causes nausea and water- 
brash. 

Ckamomilla. — Fluent, acrid discharge from the nose. Hoarse- 
ness and cough, from rattling of mucus in the bronchi. Suffo- 
cative constriction in the upper part of the chest with constant 
desire to cough. Stitches in the chest (bry.). Inability to 
swallow solid food (opp. ignatia). Children want to be carried 
and are very irritable. 

Cimicifuga.— Heat in the head with fluent, watery coryza. 
Stoppage of the nose, with great sensitiveness to the open air. 
Severe pain in the head and eyeballs, aggravated by motion 
(bry. ). The top of the head feels as if it would fly off (bapt. ). 
Chilliness with aching pain in the limbs. Excessive muscular 
soreness (am.). Cough excited with every attempt to speak 
(phos.). Alternate constipation and diarrhea (bry.). 

Cilia. — Violent sneezing. The child dont want to be touched. 
Dry, hacking cough at night. Gagging cough in the morning 
after rising. "White turbid urine. Worm affections (clienop., 
mere. ) . 

Coiiium. — Burning in the eyes. Hacking, almost constant, 



264 LECTUKES ON FEVERS. 

cough; worse at night when lying down (hyos.). Palpitation of 
the heart after drinking. Intermittent now of nrine. Exhaus- 
tion and f aintness. In aged persons. 

Brosera. — Pressing headache in the temples. Hoarseness 
with oppression of the chest, worse from talking (caust, phos.). 
Barking cough (rumex). Cough with vomiting {ipecac, tart 
emet). Rheumatic pain in the arms, at night. Patient supports 
the chest with the hands (eupat). 

Eryngium. — Severe headache with fluent coryza. Raw, smart- 
ing, burning sensations in the throat and larynx. Irritating 
cough with expectoration of tenacious yellow mucus. 

Eupatorium perf. — Coryza, with sneezing, hoarseness and 
aching pains all over as if bruised (am.). Headache with pain 
and soreness of the eyeballs ; photophobia. Cough with retch- 
ing (dros.). Hacking cough in the evening, with soreness in the 
chest (caust). Cough before and after meals. Intense aching 
and soreness in the back and limbs (am.). Soreness in the re- 
gion of the liver (bry., mere). 

Euphorbium. — Soreness in the back of the head. Burning, 
as from a flame, from the throat to the stomach. Spasmodic 
cough,with stitches extending from the pit of the stomach to both 
sides of the chest. Dry, hollow cough from tickling in the chest 
or throat. Profuse watery diarrhea with colic and great pros- 
tration. Dysenteric symptoms (mere). 

Euphrasia. — Profuse, fluent, bland coryza, with scalding tears 
(opp. ars.); aversion to light. Burning in the eyes with lachry- 
mation. Dull frontal headache (mere). Catarrhal hoarseness 
(hepar). Dry, tickling, laryngeal cough during the day, relieved 
by eating and drinking. Cramp-like pains in various parts. 

Gelsemium. — Chilliness along the spine; cannot leave the fire 
without feeling chilly. Sneezing, with tingling, especially in 
the left nostril (graph.). Stoppage of the right nostril; irritat- 
ing discharge from the left nostril with scalding sensation. 
Sensation as of a band drawn tightly around the head above 
the ears (mere). Bruised feeling in the eyes (bry.). Shooting 
pains in the ears when swallowing. Sore throat, with collection 
of mucus. Hard, painful cough with soreness in the chest. 
Neuralgic and rheumatic pain in the extremities (cimicifuga 



LEADING INDICATIONS. 265 

Thus). Copious discharge of limpid urine relieving the head- 
ache (phos. acid). Liability to take cold from every change in 
the weather (dulc). 

Hepar sulph. — Tensive headache above the nose (mere). In- 
flammation of the nose; coryza; acuteness of sense of smell. 
Darting pains in the ears, with cracking noises when blowing the 
nose. Feeling of sand in the eyes (sulph.). Koughness and 
scraping sensations in the throat (nux). Cough with constant 
hoarseness. Sensation as of a fishbone in the throat (nit. acid). 
Cough caused by uncovering any part of the body (rhus). Lar- 
yngotracheal catarrh. Great desire for acids, especially vinegar 
(bry., nux). 

Hydrastis. — Dull, heavy frontal headache (mere). Sneezing, 
with fullness over the eyes, and profuse secretion of tears 
(eupli.). Copious discharge of thin watery mucus, with smart- 
ing and rawness in the nose, worse in the open air. Eawness, 
soreness and burning, in the throat and chest (mere. cor.,). Dry, 
harsh, rattling from tickling in the larynx. Great weakness and 
prostration. In weak and debilitated individuals. 

Hyoscyamus. — Pressing pinching at the root of the nose and 
malar bones. Dry, spasmodic cough, worse at night and on ly- 
ing down, relieved by sitting up (puis.). In old persons. 

Iodine. — Dry coryza, becoming fluent in the open air. Ca- 
tarrhal deafness. Hoarseness with constant hemming and hawk- 
ing. Dry, morning cough from tickling in the larynx and burn- 
ing in the chest. Swelling of the cervical and bronchial glands. 
Progressive emaciation. 

Ipecacuanha. — Coryza with stoppage of the nose. Incessant, 
dry, titillating cough with dyspnoea. Rattling of mucus in the 
chest. Pale face, with blue margins around the eyes. Inde- 
scribable sick feeling in the epigastric region. In delicate chil- 
dren. 

Iris vers. — Constant sneezing with neuralgia of the head, 
eyes and temples. Headache with blurred vision. Dull, heavy 
throbbing pains in the forehead and right temple (bry.). Dry, 
tickling cough with smarting and burning in the throat. Taste- 
less or acid eructations. Light, mushy, painless stools. Burn- 
ing in the anus as if on fire after stool. Severe, shooting pains, 
especially in the small joints. 



266 LECTURES ON FEVEBS, 

Kali bicli. — Frontal headache, usually over one eye (sang.). 
Lateral headache in small spots. Fluent, acrid coryza, excoriat- 
ing the nose and lips (arum, mere. cor.,). Sensation as of a hair 
in the nose (Hydrastis). (Edematous swelling of the eyelids 
(apis). Pressive pain at the root of the nose. Tickling in the 
larynx causing coughing. Battling cough with viscid stringy 
expectoration. Hoarseness in the morning (canst.). Feeling of 
coldness in the. stomach and bowels. Lameness in the right arm- 
wandering pains (puis.). 

Kali liyd. — Violent sneezing, and running of acrid water from 
the nostrils (allium). Sensation of fullness and tightness at the 
root of the nose, with throbbing and burning pains in the nasal 
and frontal bones (kali bicli. ). Burning in the eyes with profuse 
lachrymation. Bawness in the larynx; stitches from the ster- 
num to the back. Short, dry, hacking cough with whitish and 
greenish expectoration. 

Lacliesis. — Fluent coryza and lachrymation (ars., kali hyd.) 
Dryness of the mouth with burning as from pepper. Throat 
sore, especially when touched (apis). Frontal headache with 
trifling discharge from nostrils. As soon as a profuse discharge 
sets in the head and throat symptoms ameliorate. Pain in the 
left ear when swallowing. Dry, spasmodic, nightly cough, ag- 
gravated by sleep. Gagging, persistent cough from tickling in 
the throat. Stitching pain in hemorrhoidal tumors when cough- 
ing or sneezing. 

Lycopodium. — Catarrh of the frontal sinuses; pressing or 
tearing frontal headache, especially in the right side of the head. 
Bedness of the eyelids with lachrymation. Violent coryza with 
acrid discharge (arum, mere). Accumulation of mucus in the 
throat. Lemon-colored expectoration. Sore, pressive pain in 
the region of the liver (chel). Swelling of the cervical glands 
(mere). Dry cough day and night as if from fumes of sulphur 
in the larynx. Hepatization of the lungs (bry., plws.). 

Mercurius. — Frequent sneezing with profuse, fluent, corrosive 
coryza (arum, kali hyd.). Burning in the eyes and profuse flow 
of tears. Catarrhal headache. Inflamed and ulcerated tonsils 
(bell., liepar). Hoarseness with rawness and tickling in the 
larynx (plios.). Bheumatic pains with sore throat, not relieved 



LEADING INDICATIONS. 267 

by sweating. Stitches in the right side of the chest when sneez- 
ing or coughing (bry.). Violent night cough. Flying pains in 
all parts of the body from coughing. Constipation, or mucus, 
bilious diarrhea. Yiolent and constant thirst for cold drinks. 
In children and old people. 

Nux YOift. — Coryza, fluent in the morning and during the day, 
but dry at night. Dry, racking cough with headache as if the skull 
would burst; great soreness of the epigastrium. Coryza with 
sneezing, worse in the morning and after eating. Sour taste in 
the mouth every morning (bry.). Great debility with over-sen- 
sitiveness of all the senses (cinch.). Drowsiness in the day- 
time and after eating. 

Pliellandrium. — Headache, with pain as from a weight on the 
top of the head; aching and burning in the temples above the 
eyes. Pain in the eyes with lachrymation, photophobia and con- 
junctivitis. Hoarseness with roughness in the throat (hepar). 
Dry cough with shortness of breath and stitches in the chest. 
Scanty urination with violent burning after a discharge. 

Phosphorus. — Throbbing headache; headache over the left 
eye (aconite); worse in the evening. Frequent sneezing, with 
alternately fluent and dry coryza. If ose swollen, dry and stopped 
up. Difficult hearing, especially of the human voice. Hoarse- 
ness and roughness of the voice (canst., hepar). Dry, tickling 
cough with tightness across the chest, relieved by pressure upon 
the external walls. Cough worse, before midnight, from reading, 
laughing or speaking, and on going into the cold air (bry., 
rumex); better after sleeping (opp. lack.). Mucous rales in 
both lungs, especially in the lower lobes (ipecac, tart. emet,). 

Phytolacca. — Pressive, sore pain in the forehead, worse on 
the right side. Sensation of soreness, deep in the brain. Burn- 
ing, smarting in the eyes, with lachrymation. Thin, watery dis- 
charge from one nostril with stoppage of the other (gels., sepia). 
Drawing sensation about the root of the nose. Great pain in 
the root of the tongue when swallowing. Excruciating pain 
through both ears when swallowing. Dry, hacking cough, with, 
hawking, excited by tickling in the larynx and dryness in the 
pharynx. Rheumatic pains in the extremities. Derangement 
of the digestive organs. 



268 LECTUEES ON FEVEKS. 

Pulsatilla. — Bursting, throbbing headache in the forehead 
and temples, relieved by pressure {apis). Fluent or dry coryza, 
with frequent sneezing, and loss of taste and smell {sidph.). 
Stoppage of the nose in the evening and in a warm room. In- 
flammation of the eyes with profuse lachrymation (euph.). 
Darting, tearing, pulsating pains in the ear at night {mere). 
Roaring in the ears, as if from the rushing of waters. Dry cough, 
at night or in the evening, especially after lying down {hyos.). 
Loose cough, with vomiting of mucus, and nightly diarrhea. 
Aversion to fat food (opp. mix). Gastric disturbance from rich 
food or pastry {nux). Drawing, tearing pains frequently shift- 
ing from one part of the body to another {kali bich.). Especially 
adapted to females and children. 

Rhus tox. — Frequent, violent, spasmodic sneezing. Hot, acrid 
discharge from the nose. Aching, pressive pains in the eyes 
{caust.); oedema of the lids {apis). Swashing and jarring sen- 
sations in the brain {nairum). Short, dry cough from tickling 
in the bronchi (rumex). Putting the hands out of bed brings 
on the cough {hepar). Pain and aching in the limbs, worse 
during rest, better during exercise. Great restlessness, must 
change position often (opp. bry.). Typhoid symptoms. 

Rumex crisp. — Fluent coryza, with violent sneezing, and pain- 
ful irritation of the nostrils; worse towards evening and at night. 
Dry, scraping sensation in the throat, with copious secretion of 
mucus in posterior nares. Hoarseness, with pain and rawness in 
the larynx {plios.). Violent, dry cough, excited by tickling in 
the larynx {sang.), often almost continuous; worse at night from 
exposure to cool air, and on lying down {dros., plios.). Brown 
and watery morning diarrhea {sulph.). Great debility, with 
restlessness and extreme sensibility to the open air {rims). 

Sabadilla. — Headache, with fluent coryza. Lachrymation, 
with redness of the eyes. Chilliness, with heat and redness of 
the face. Cough worse on lying down {hyos., lach.). Burning 
and stitches in the chest. Bed spots on the chest. Pain in the 
bones as if scraped {rhus). Debility, with heaviness and relax- 
ation of the body. Aggravation of svmptoms at the same hour 
every day {cedron). 

Sauguinaria. — Fluent coryza, with frequent sneezing {eu- 
phrasia). Smell in the nose like roasted onion. Circumscribed 



LEADING INDICATIONS. 269 

redness of the cheeks. Looseness of the teeth with ptyalism 
(mere). Feeling of dryness in the throat; constant tickling at 
the entrance of the larynx; ulcerated sore throat. Catarrhal 
affections of the inner ear and Eustachian tube. Wheezing congh, 
worse at night. Dry, hacking cough from tickling in the throat- 
pit (rumex). Severe and persistent dyspnoea, with inclination 
to take deep inspirations. Diarrhea following the coryza, and 
relieving the cough. Desire for piquant, highly seasoned food. 
Wandering rheumatic pains, worse at night and from motion. 
Pneumonia with extensive hepatization (phos.). 

Sangninaria nitrate. — Violent sneezing with profuse watery 
discharge from the nostrils (euph.). Burning pain and rawness 
in the nose (ars.). Heat and burning in the eyes, with dimness 
of sight, and profuse lachrymation. Sore, aching pain in the 
right eyeball, extending into the supra-orbital region. Burning 
pain in the forehead and at the root of the nose. Catarrhal 
affections of the internal ear and Eustachian tube. Soreness and 
roughness of the throat, with sense of constriction and difficulty 
of swallowing. Accumulation of mucus in the throat and chest 
(kali bich.). Tension and burning behind the sternum with de- 
sire to cough (rumex). Cough with expectoration of large 
quantities of thick, yellow, sweetish mucus. All the symptoms 
are worse at night (mere). 

Senega. — Aching pain and tension in the eyeballs. Weakness 
of the eyes with burning and lachrymation. Acuteness of the 
sense of hearing (cann. ind. ) . Dry, shaking cough from tickling 
in the larynx. Battling cough with profuse secretion of mucus 
(tart. emet.). Cough with expectoration of slate-colored mucus. 
In old people. 

Sepia. — Fluent coryza with frequent sneezing (allium, sang.). 
Obstruction of the nose and violent, dry coryza. Swelling and 
redness of the eyes, with lachrymation; worse morning and 
evening, better during the day. Intense frontal headache. Her- 
petic eruptions on the lips. Painful sensation of emptiness in 
the stomach and abdomen (hyd., ignat ). Hoarseness with cough 
from tickling in the larynx (hepar, phos.). Dry, tickling cough 
at night (hyos.), followed by expectoration of mucus with tem- 
porary relief (ipecac). Morning cough, with greenish, salty 



270 LECTUKES ON FEVERS. 

expectoration. Stitches in the chest when coughing (bry.). 
Pain in the chest relieved by pressure (opp. calcarea). 

Sllphium. — Sneezing, with discharge of acrid mucus from the 
nose. Scraping, tickling sensations in the throat. Tightness of 
the chest; spasmodic cough; copious expectoration of yellow 
mucus. Profuse expectoration of water mixed with light-col- 
ored, stringy, tasteless mucus. 

Spigelia. — Fluent coryza, with dry heat and no thirst. Burn- 
ing pain in the right side of the head extending into the eye. 
Hyperesthesia of the fifth nerve. Otalgia with pressive pain as 
from a plug. Toothache aggravated by cold air or cold water 
(opp. coffea). Dry, hard, night cough with dyspnoea. Headache 
with hoarseness; anxiety with palpitation of the heart. 

Spongia. — Fluent coryza with frequent sneezing {allium, 
sang.). Dry coryza with stoppage of the nose {mix). Pain in 
the chest, with rawness in the throat when coughing. Dry, hol- 
low, barking or wheezing cough, relieved by eating or drinking. 
Hoarseness; larynx sensitive to the touch {lack.). Swelling of 
the sub-maxillary glands {mere). 

St annum. — Dry coryza; stoppage high up in the nose {lye). 
Neuralgic headache; the pains commence lightly, increase grad- 
ually to a high degree, and decrease again as slowly. Dryness 
and rawness of the throat. Hoarseness and roughness in the 
larynx (phos. ). Scraping cough with profuse greenish, sweetish 
expectoration. Feeling of great weakness and exhaustion in the 
chest. Faintness with weakness of the voice, worse from sing- 
ing or talking {arum). 

Sticta. — Incessant sneezing, with a feeling of fullness in the 
right side of the forehead down to the root of the nose, with 
tingling in the right nostril. Splitting frontal headache. Dry, 
racking cough in the evening and at night, excited by inspiration. 
Cough from tickling in the right side of the trachea, with op- 
pression of the chest. Excessive dryness of the mucous mem- 
brane. All symptoms worse in the afternoon; better in the 
morning and in the open air. Sleeplessness. 

Sulphur. — Fluent coryza; coryza with stoppage of the nose. 
Itching and burning in the nostrils, as if sore. Dry ulcers or 
scabs in the nose. Stitches in the throat when swallowing ( bell). 



HYGIENIC AND DIETETIC TREATMENT. 271 

Dry cough in the evening on lying down, with itching in the 
bronchi. Stitches in the chest extending back to the left scapula 
(kali carb.). Chronic cough with mucous rales. Sudden arrest 
of breathing when turning in bed. Tearing pains in the limbs, 
muscles and joints from above downward (opp. ledum). Morning 
diarrhea, driving the patient out of bed hurriedly. 

Tartar emet. — Chilliness, with sneezing, fluent coryza and 
loss of taste and smell. Much rattling of mucus in the chest 
(ipecac). Oppression of breathing, relieved by expectoration. 
Cough followed by yawning (mix), especially in children. Great 
restlessness. The child must be carried, it cries if touched 
(cham., staph.). Gastric symptoms. Cyanosis (cuprum). 

Veratrum alb. — Icy coldness of the forehead and nose. Smell 
as of smoke before the nose ; painful dryness of the nose ; fre- 
quent, violent sneezing. Difficult respiration with tightness 
and constriction in the chest. Deep, hollow cough, occurring 
in shocks. Icy coldness of the extremities. Sudden sinking of 
strength (ars.). Capillary bronchitis (chel.); oedema of the 
lungs (moschus). 

Wyethia. — Dryness of the throat. Burning and tickling in 
the epiglottis. Dry, hacking cough, caused by tickling in the 
epiglottis. Pain in the forehead over the right eye. Sharp pain 
and soreness in the right hypochondrium. Diarrhea with dark 
brown evacuations. 

HYGIENIC AND DIETETIC TREATMENT. 

Individuals suffering from an attack of influenza should remain 
indoors. The diet — from which meat must be excluded — should 
be plain and easily digested. The various fruit syrups may be 
used as drink in moderate quantities. Weak wine-whey is fre- 
quently useful. When the stomach is irritable koumyss will 
prove grateful. Sound claret may be allowed, if desired by the 
patient. Free inunctions about the brow and over the bridge of 
the nose, are of service when the coryza is excessive. When the 
head pains are severe, warm applications or a flannel cap may 
be used. The tickling cough, which is ofttimes very annoying, 
may be allayed to a considerable extent by resorting to steam 
inhalations. 



LECTUEE XVIII. 

Typhus Feyer. 

You will doubtless remember that I completed the history of 
the miasmatic-contagious fevers at my last lecture. To-day, I 
will commence the history of the third class of fevers — the con- 
tagious fevers. The first in order in this class is Typhus Fever. 

Definition. — Typhus fever may be defined as an acute, highly 
contagious fever, having an average duration of fourteen days, 
due to an unknown specific poison, arising usually in connec- 
tion with overcrowding, imperfect ventilation and filth, and oc- 
curring in more or less extensive epidemics. It is characterized 
by sudden invasion, usually with a chill; great and early pros- 
tration; deeply flushed face; frontal headache; injected eye; 
pain in the back and thighs; pungent heat of the skin, with an 
ammoniacal odor; mulberry -rash on the fifth day, first on the 
sides of the chest or abdomen, frequently becoming petechial 
on the eighth, ninth or tenth day; furred tongue; usually con- 
stipation with flat or even scaphoid abdomen; a high temperature 
and a quick pulse; after the first week, delirium; stupor or coma; 
a dry and brown tongue; tremors and involuntary discharges. 
Death may take place from either coma or syncope, or as a result 
of complications. No constant specific lesions are found upon 
examination after death. Relapses are infrequent; a second 
attack is of rare occurrence. The incubation is from five to 
fourteen days. 

Synonyms. — It has been known and described as: Infectious 
fever. Ship fever. Emigrant fever. Contagious fever. Pesti- 
lential fever. Petechial fever. Putrid continued fever. Epi^ 

(272) 



GEOGRAPHICAL LIMITS. 273 

deinic fever. Camp fever. Malignant hospital fever, and Irish 
ague. 

History. — Although the description given by Tlmycidides, of 
a pestilential fever which prevailed in Athens at the time of the 
Peloponnesian war, resembles in outline that of typhus fever, 
the first satisfactory account on record is that given by Fracas- 
torius in 1501, of a disease which spread from Cyprus into Italy 
and overran all Europe, and had prevailed for over twenty years. 
During the sixteenth century many accounts were published of 
destructive epidemics that prevailed in Tuscany, Hungary and 
France, spread all over the continent, and extended to Great 
Britain and Ireland. 

Between the years 1609 and 1638, all Europe was devastated 
by famine and by a contagious fever which resembled typhus. 

The great plague of London in 1665 was preceded and fol- 
lowed by a continued fever, which bore a striking resemblance 
to typhus. In Ireland the disease was described as the "Irish 
Ague." About the beginning of the last century, a continued 
fever resembling typhus spread throughout Europe and the 
British Isles, and was most prevalent in over-crowded localities. 
From 1735 to 1803 several severe and fatal epidemics appeared 
in Ireland, and extended into various parts of England. From 
1816 to 1819 wide-spread epidemics occurred in Ireland and in 
Northern Italy, while limited epidemics appeared in different 
parts of Europe. During the six years following 1826 it was 
endemic in Great Britain and Ireland, but became again epi- 
demic in 1842 and 1846. "Wide-spread epidemics appeared in 
Ireland, Bussia and Prussia, in 1847, 1857 and 1868. From 1854 
to 1856 typhus prevailed very extensively among the armies in 
the Crimea. 

Bestricted epidemics have appeared on this continent since 
the beginning of the present century. The first epidemic broke 
out in the Boston poorhouse, in 1816. Since that time it has 
repeatedly appeared in consequence of direct importation. It 
has raged on several occasions at New York, particularly in 1818, 
1825, 1827 and 1861-65. It appeared at Buffalo in 1850-52, and 
at Philadelphia in 1820, 1836, 1864 and 1880. 

Geographical Limits. — The chief geographical center of ty- 
phus fever is Ireland. Other centers are found in Northern 



274 LECTURES ON FEVERS. 

Italy, and the Baltic provinces of Russia. The disease has 
spread from these centers throughout Europe, Asia and the 
British Isles; and has been observed, under circumstances of 
direct importation, principally in the coast cities of the Northern 
States of this country, in the neighboring Dominion of Canada 
and in the West Indies. It has not, as yet, been observed in the 
Southern States, Africa or Australia. 

Etiology. — The causation of typhus fever may be conven- 
iently studied under the two divisions, predisposing and exciting 
causes. 

1. The Predisposing Causes. — Of the predisposing causes, 
over-crowding, filth and starvation are the most important. The 
majority of the great epidemics of typhus have generally oc- 
curred in times of scarcity among the poor and under-fed of 
large cities, living huddled together in crowded and illy-venti- 
lated apartments. Fatigue, want of sleep, frequent exposures, 
previous illness, anxiety and other depressing emotions materi- 
ally predispose to the disease. Hence medical students, hospital 
internes, nurses, nervous people and individuals recovering from 
even slight illness, not infrequently contract typhus fever. Ty- 
phus is for the most part a disease of adult years, although all 
periods of life are liable to its attacks. It is essentially a dis- 
ease of cold and temperate climates, and is most prevalent dur- 
ing the winter months. Damp or marshy soil favors its devel- 
opment. 

2. The Exciting Cause. — The nature of the exciting cause of 
typhus fever remains, as yet, unknown. The majority of observ- 
ers, however, agree in describing the infecting principle as an 
organized germ, emanating from the body of an affected individ- 
ual, and capable of indefinite reproduction. And careful clinical 
observation has established the fact that this specific typhus 
poison may be communicated directly from the sick to the heal- 
thy in the expired air, and in the cutaneous exhalations of pa- 
tients. The peculiar pungent odor conveyed by the breath and 
emitted from the bodies of typhus patients is, as a rule, strong 
in proportion to the intensity of the poison. The germs are 
believed by many, capable of retaining their vitality for a great 
length of time, and of being carried in the bedding and in the 
clothing of patients, which act as fomifes. In this way it is 



ETIOLOGY. 275 

argued that houses, ships and hospital wards may readily become 
hot-beds for the production and spread of the disease. Loomis, 
and other more recent writers, however, are doubtful whether the 
disease can be communicated by f omites alone, even when highly 
impregnated, and maintain that it is necessary for the subject of 
the contagion to have been brought in contact with an infected 
person, or within the atmosphere immediately impregnated with 
his exhalations. The contagious distance of typhus fever — the 
distance at which the specific poison may be transmitted by the 
breath or cutaneous exhalations, through the atmosphere, in the 
open air — is somewhat less than that of small-pox, which has 
been demonstrated by actual experiment to be two and one-half 
feet. 

In large and well-ventilated apartments the risk of contagion 
is greatly lessened ; while in small, badly- ventilated rooms, it is 
largely increased. There are no facts to prove that the disease 
is diffused from one house to another or from hospitals to ad- 
joining houses except by intercommunication. It is occasionally 
contracted in the dissecting room, by dissecting bodies dead 
with typhus. 

The danger of contagion is slight during the first week of 
typhus, but is largely increased from the close of this period, 
until convalescence becomes established. In the majority of in- 
stances the disease attacks an individual but once. All persons, 
at all times, are not equally susceptible. A special constitutional 
idiosyncrasy occasionally exists, which affords an immunity. 

The length of the period of incubation varies from five to 
fourteen days. 

Summing up the known facts in the etiology of this fever, we 
are led to state: 

1. That there exists a specific typhus poison, which is undoubt- 
edly present in the body exhalations and in the expired air of 
typhus patients. 

2. That it is communicated only by personal contagion — the 
contagious distance being about two feet. 

3. That a concentration of the poison is necessary to produce 
the infection, and that where there is free ventilation personal 
contagion is confined to limited areas. 

4. That it is taken into the body mainly through inspired air- 

5. That over-crowding and deficient ventilation, even when 



276 LECTURES ON FEVERS. 

conjoined with innutrition, do not produce typhus, but favor, by 
deteriorating the constitution, its extension and increase its 
severity. 

6. That it ordinarily occurs but once in a life time. 

7. That in this country it is, as a rule, an imported disease. 

Clinical History. — The advent of typhus fever is usually ab- 
rupt. Occasionally there is a prodromal stage of a few days 
duration, marked by general lassitude, headache, anorexia, ver- 
tigo and nocturnal restlessness. In a majority of the cases there 
are no prodromes, the disease being ushered in by a short, sharp, 
sudden chill or by chilly sensations. At times the chill or chilly 
sensation recurs at irregular intervals for several days; and, in 
children, repeated vomiting not unfrequently occurs. A sense 
of extreme prostration soon follows the initial chill, attended, as 
a rule, by intense and steadily increasing frontal headache. The 
fever increases rapidly, and the temperature may rise during the 
first twenty-four hours as high as 105° Fahr. or 106° Fahr. 
Notwithstanding the high temperature, the patient frequently 
complains of a sensation of coldness. The skin becomes hot, the 
face flushed, the eyelids swollen and injected, and the respira- 
tions slightly hurried. Occasionally there is sneezing with 
slight cough and soreness of the throat. More or less severe 
pain in the back, and sore, dull pains in the limbs, especially in 
the thighs, are constantly present. The tongue is at first pale, 
swollen, and covered with a whitish fur; later it is covered with 
a yellowish-brown coating, and displays a tendency to become 
dry, brown and fissured, and ofttimes tremulous. Nausea is 
sometimes present; vomiting rarely occurs. The bowels are, as 
a rule, constipated, exceptionally there is slight diarrhea. The 
spleen becomes enlarged early in the disease, and there is slight 
tenderness in both hypochondria. 

During the first week of the fever the temperature varies from 
103° Fahr. or 104° Fahr. in the morning, to 104° Fahr. or 106° 
Fahr. in the evening. 

The pulse is accelerated from the beginning of the attack, 
ranging from 100 or 110 in the morning, to 120 or 130 in the 
evening. It is at first full, but soon becomes soft and compressi- 
ble; later it grows feeble, and is not unfrequently dicrotic. As 
the fever progresses the expression of countenance becomes dull 



CLINICAL HISTORY. 277 

.and stupid, and the cheeks assume a mahogany appearance. The 
sleep is disturbed, and between sleeping and wakirjg there is 
slight delirium. 

Between the fourth and eighth, usually on the fifth day, the 
characteristic eruption appears, first upon the sides of the chest 
and abdomen, gradually extending over the whole anterior por- 
tion of the body, except the neck and face. It consists of nu- 
merous roseola-like spots, varying in size from a mere point to 
three or four lines in diameter, and is more marked upon the 
trunk than on the extremities. It is of tener wanting in children 
than in adults; in the former it frequently resembles the erup- 
tion of measles. At first, the spots are of a dark red or dirty 
rose-color, appear slightly raised above the surface of the sur- 
rounding skin, and temporarily disappear on pressure. After 
two or three days they become darker in color, and appear as 
faint, irregular, dirty brown stains. They are now no longer 
elevated, and do not entirely disappear on firm pressure. A 
faintly reddish ill-defined mottling or marbling, appearing as if 
it were a little distance below the surface of the skin, between 
the spots or groups of spots is generally present. The spots and 
the sub-cuticular mottling may exist separately and alone, usu- 
ally they occur together and constitute the " mulberry rash " of 
typhus. 

The course of the eruption is typical. The rash is fully de- 
veloped in less than forty-eight hours, and its copiousness rep- 
resents generally a corresponding gravity of the disease. Each 
spot or patch remains visible from its first appearance until con- 
valescence is established or death takes place. In a certain pro- 
portion of cases the typhus spots become petechial, and in severe 
grades of the fever they may be converted into dark red stains. 
This occasional change in the character of the eruption has led 
to the erroneous title, " petechial typhus." 

At the close of the first week the headache disappears, and 
delirium, usually low muttering, sometimes acute and boisterous, 
comes on. Occasionally the delirium is active and persistent 
from the start, and physical restraint is rendered necessary. 
About the middle of the second week as the symptoms continue 
to deepen, the intense nervous excitement abates. The patient 
now becomes drowsy, passes into a state of " coma vigil," and 
lies for hours apparently unconscious with the eyes open as 



278 LECTUKES ON FEVERS. 

though awake. This "coma vigil" or watchful coma is a state 
of apparent, rather than complete coma, from which the patient 
can be easily aroused. It is usually attended with great mental ac- 
tivity, and is of unfavorable omen. Persons of active brain fre- 
quently have the most distressing fancies during this period. If 
the case terminates in recovery the patient emerges with a dis- 
tinct remembrance of all the horrid visions that passed before his 
imagination. At this stage of the fever the face appears flushed, 
the conjunctivae are injected, and there is a dusky pallor about 
the nostrils and lips. The pains in the limbs and back are no 
longer complained of, and involuntary twitchings occur. The 
respirations become quickened, and there is a dry, annoying 
cough with scanty mucous expectoration. The breath and cuta- 
neous exhalations give off an ammoniacal or "mouse-like" odor. 
The heart-sounds become feeble and indistinct; the pulse is small 
and ranges from 110 to 140 per minute. The tongue is dry and 
fissured, and is protruded with difficulty. Swallowing becomes 
difficult on account of dryness of the pharynx; and sordes col- 
lect upon the teeth and lips. The urine becomes scanty and high 
colored, and either collects in the bladder or dribbles away. 

As the disease progresses, if the case is tending towards a 
fatal termination, the stupor deepens, the coma becomes more 
and more profound, and the patient lies on the back utterly in- 
different to everything going on around him. The tongue can no 
longer be protruded from the mouth, the hands tremble, the ex- 
tremities are cold, and the muscular prostration becomes extreme. 
The pulse rises to 140 or 150 per minute, and is small and weak; 
at times it becomes irregular. The temperature which has re- 
mained with but slight morning and evening variation at 105° 
Fahr., may rise to 107° Fahr. or 108° Fahr. before death. 

When a fatal termination takes place, which is possible as 
early as the fifth day, or before the end of the first week, but 
mostly between the tenth and seventeenth days, the mode of death 
is by coma, by asphyxia, or by heart failure. 

In cases that tend towards a favorable termination there oc- 
curs, usually about the fourteenth clay, sometimes as early as the 
tenth day, a sudden amelioration of all the symptoms, associated 
with a critical defervescence. The pulse and temperature sud- 
denly fall, and reach the normal or fall slightly below it, in from 
one to two days. The stupor and coma rapidly disappear, and. 



CLINICAL HISTORY. 279 

after a prolonged and refreshing sleep, the patient awakes to 
consciousness as from a long and oppressive dream. The urine 
becomes increased in quantity, and there is a copious deposit of 
urates. The eruption fades and slowly disappears. The tongue 
cleans and becomes moist at the edges. The appetite improves, 
the strength begins to return, and the patient enters upon a rapid 
convalescence. The hair frequently falls off as recovery takes 
place. Deafness and lack of mental vigor which are apt to con- 
tinue far into convalescence, gradually disappear. 

Abortive cases of typhus presenting all the characteristics of 
the initial stage of the disease, occasionally appear during the 
prevalence of typhus epidemics. Usually there is no delirium, 
and at the end of the second, third or fourth day, a critical def- 
ervescence occurs, accompanied by sweating and diarrhea. 

True relapses are rare. 

Complications. — The complications of typhus fever like those 
of typhoid fever are numerous and important, and are not un- 
f requently the cause of death. They vary in different epidemics ; 
in some they are either cardiac or pulmonary ; in others they are 
all cerebral. 

The pulmonary complications of typhus, among which may be 
mentioned, laryngitis, bronchitis, lobular pneumonia, pulmonary 
gangrene and phthisis, always approach insidiously. Hurried 
respiration and lividity of the face are not uncommon danger 
signals. In all cases you will do well to institute daily physical 
exploration of the chest. 

Laryngitis may occur as an occasional complication. It usu- 
ally appears as an acute oedema glottidis, although at times it is 
croupous in character. Its advent, which is always insidious, 
should be anticipated whenever there is great swelling of the 
glands of the neck or extensive tumefaction of the mucous mem- 
brane of the pharynx. 

Bronchitis may occur at any period of the fever. It is devoid 
of danger so long as it is confined to the larger bronchial tubes. 
But when it becomes diffuse and extends into the smaller tubes, 
it may lead to atelectasis and secondary lobular pneumonia, and 
so diminish the breathing capacity as to cause death. 

Lobular pneumonia. — The pneumonia of typhus is lobular in 
character. It is frequently preceded by bronchitis and displays 
a tendency to terminate in abscess or pulmonary gangrene. It 



280 LECTURES ON FEVERS. 

is manifested by the usual signs, dullness confined to one ] ung 
(usually the upper part), bronchial respiration and rusty sputa. 
Pulmonary gangrene is an occasional, but generally fatal com- 
plication. Its signs are,- dullness on percussion, with coarse 
mucous rales, greenish or brownish and horribly foetid expector- 
ation, rapid and oppressed breathing, pallor and great prostra- 
tion. Purulent and serous pleuritic effusions occasionally occur, 
and sometimes phthisis supervenes during convalescence. 

Meningitis is the principal cerebral complication. It is most 
liable to occur during the second week of the fever, and is of tener 
met with in children than in adults. Its presence is manifested 
by intense bi-lateral headache, with restlessness which shows 
itself by constant attempts to get out of bed, redness of the face 
and eyes, intense sensitiveness to light and sound, contracted 
pupils, with contractions of the flexor muscles of the arm and 
leg, followed by somnolence lapsing into coma. Dilatation of 
the pupils with slow stertorous breathing, and an intermitting 
almost imperceptible pulse, immediately precede death. 

Feebleness of intellect and attacks of mania, show themselves 
in a small proportion of cases during convalescence. They are 
commonly transient, lasting only a few days or weeks. 

Paralysis may occur as a sequel of typhus, but usually ter- 
minates within a limited period after recovery. Hardness of 
hearing, which is a frequent attendant during the course of the 
fever, commonly disappears as convalescence becomes estab- 
lished. Occasionally permanent deafness occurs as a result of 
inflammation of the external or of the middle ear. Transient 
dimness of vision has been observed' in some epidemics, and 
perforating ulceration of both cornese occasionally occurs as a 
result of prolonged exposure of the eyeballs. 

Croupous nephritis occasionally occurs during the course of 
typhus. Its occurrence is indicated by urinary suppression, and 
by the presence of albumen and of hyaline, and blood casts in 
the urine. 

Glandular swellings occasionally occur as complications, and 
are, as a rule, most frequently observed in adults. They may 
appear either in the early days of the fever or immediately after 
the crisis. They are most apt to involve the parotid and the 
sub-maxill ary glands; less frequently the mammae and the axil- 
lary and inguinal glands become implicated. The swellings, 



ANALYSIS OF CHART. 281 

usually form rapidly, and speedily tend to suppuration; occasion- 
ally resolution occurs. When parotitis occurs, it is not infre- 
quently associated with facial erysipelas or with, extensive 
inflammatory oedema of the neck, and oedema of the glottis. 

Sub-cutaneous extravasations of blood are not uncommon 
in some epidemics. While hemorrhages from the nose, bowels, 
kidneys and uterus, have been occasionally observed. 

Boils, and diffuse inflammation of the sub-cutaneous tissues 
resulting in purulent infiltration, are not infrequently met with 
in some epidemics. Wounds and ulcerated surfaces, and even 
parts not subjected to pressure, may at times, in consequence of 
arterial thrombosis, become gangrenous. 

Pycemia with purulent deposit in the smaller joints is an occa- 
sional though rare occurrence. It commonly appears about the 
time of the crisis and is manifested by severe chills, rapid and 
feeble pulse, jaundice, delirium, great prostration and redness, 
tenderness and swelling of the joints. 

Bed-sores, which are common and troublesome complications 
of typhoid fever, are rarely present in ordinary typhus fever. 
In protracted cases, however, they are apt to appear, especially 
over the sacrum and trochanters, and may, if extensive, lead to 
exhaustion and death. 

Duration. — The average duration of typhus fever is from 
thirteen to fifteen days. It is shorter in childhood and youth, 
than in middle and advanced life. Mild cases may terminate at 
the end of the first week or at the beginning of the second week. 
Uncomplicated cases rarely last longer than twenty days. 

Complications may protract the course of the disease to four, 
iixe or even six weeks. The day of crisis is usually between the 
tenth and sixteenth days. The mean duration of the fever, which 
is fourteen days, is usually longer at the beginning than at the 
close of an epidemic. 

ANALYSIS OF CHART. 

The Xervous System. — Headache is one of the earliest and 
most constant symptoms of typhus. It is usually present at the 
onset of the attack, and is frequently associated with vertigo. 
It is dull or heavy in character, and is located mainly in the fore- 
head and temples; exceptionally it is confined to the vertex or 
occiput. It remains, as a rule, persistent during the first week 



282 



LECTUEES ON EEYEES. 

CHART XII— Typhus Fever. 



Nature : 


Epidemic. Highly Contagious. 


Initial Symptom: 


A short, sharp, sudden chill. 


Stages : 


First Week. 


Second Week. 


Third Week. 


Face : 


Flushed. Mahogany 
colored cheeks. 


Dull, heavy express- 
ion. 


Countenance natural. 


Eyes: 


Watery and injected. 


Pupils contracted. 


Normal. 


Ears: 


Noises in the ears. 


Deafness. 


Deafness disappears 


Temperature : 


103° to 106" on fi stday, 

maximum on 3d 

or 4 th day. 


Slight remission from 
7th to 10th day. Crisis 
from 8th to 14th day 


Sudden defervescence 


Pulse: 


100 to 120. First full, 
then soft. 


110 to 140. Weak heart 
impulse after 6th 
day. 


Declines rapidly. 


Respiration, eta: 


20 to 30 per minutei 
catarrhal symp- 
toms. 


30 to 40 or 50 per min- 
ute. Bronchitis. 


Returns to normal. 


Cutaneous 
Surface : 


Dry skin. Pungent 
heat. 


"Mouse-like" odor. 


Bran-like desquama- 
tion. Temporary 
los« of hair. 


Eruption : 


"Mulberry rash" on 
5th day. On abdo- 
men and extremities 


Each spot lasts until 
recovery or death. 
Petechias. 


Gradually disappears. 


Nervous System: 


Frontal headache. 
Wakefulness. Pain 
in the thighs. Pros- 
tration. 


Delirium. Deafness. 
Coma vigil. 


Muscular pains. Rest- 
ful sleep. 


Tongue: 


First white, then 
brownish- yellow. 
'1 hirst. 


Dry, dark, fissured 
Tremulous. 


Clean and moist. 


Intestinal Canal : 


Nausea. Constipation. 


Constipation Occa- 
sionally slight diar- 
rhoea. 


Constipation. 


Urine: 


Diminished. High col- 
ored. Excess of 
urea. 


Transient albuminu- 
ria. Retention, 


Pale. Increased. 


Complications : 


Glandular swellings. Cerebral and pulmonary difficulties. 


Duration: 


Average duration 13 or 14 days. 


Mortality : 


Varies from 6 to 20 per cent. 


Lesions: 


No constant post mortem appearances. 


Incubation: 


Two weeks. 


Conta.ious Dis- 
tance : 


About two feet. 


Relapses: 


Relapses are extremely rare. 


Recurrence: 


Typhus occurs only once in a lifetime. 



ANALYSIS OF CHAET. 283 

or ten clays, after which it gradually disappears upon the advent 
of delirium. 

Delirium is a common symptom, and appears usually about 
the eighth day. In rare instances it is present at the onset of 
the disease, occasionally it remains absent until near the crisis. 
At whatever period it is developed, it will remain until after the 
time of critical defervescence. The character of the delirium 
varies greatly. It is generally quiet, and consists of low mutter- 
ings or incoherent ramblings; less frequently it is active and 
noisy, and resembles that of delirium tremens or of the Irish 
"whisky fever." Active, noisy delirium occurs most frequently 
amongst the intelligent classes, and in young persons of active 
brain; the low muttering form is more liable to be present in 
the aged, and amongst illiterate people. At first the delirium 
occurs only at intervals, during the night-time; later on it be- 
comes continuous, and is then worse at night. 

Nocturnal wakefulness is a prominent and distressing symp- 
tom in the early days of the fever. At times there is drowsiness 
in the day time, with alternate wakefulness and delirium at 
night. Not infrequently the patient lies for hours, pale and ex- 
pressionless, and almost pulseless, with the eyes wide open and 
the skin bathed in a cold perspiration. Though apparently un- 
conscious, he is evidently awake, but absolutely indifferent and 
insensible to everything that is going on around him. To this 
condition, which is almost always followed by a fatal termination, 
the by no means significant term, coma vigil, has been applied. 
At any time, and more especially in the advanced stage of the 
disease, the occurrence of hysterical manifestations, should make 
your utterances guarded as to coming nervous symptoms. 

As the fever progresses towards a fatal termination, the drow- 
siness deepens by imperceptible gradations, first into stupor and 
then into profound coma. Occasionally coma develops suddenly,, 
and is then apt to be associated with albuminous urine. 

Loss of muscular strength is a prominent and early symptom 
of typhus. In the majority of cases the patient is compelled to 
take to the bed, on account of weakness, from the first day of 
the fever. Not infrequently the debility becomes so extreme, 
that the patient is unable to rise, or to even turn in bed. Th& 
prostration generally increases as the disease advances, and is 
often complete about the ninth or twelfth day. The position o£ 



284 LECTURES ON FEVERS. 

the patient in bed, is usually on the back; with the increasing 
prostration there is almost always a tendency to sliding down 
in bed. 

Along with the marked and steadily increasing debility, there 
is apt to be paralysis of the muscles of the rectum and bladder 
The urine and faeces may be passed involuntarily, in consequence 
of paralysis of the anal and vesical sphincters. Sometimes the 
urine is retained, and there is over-distension of the bladder in 
consequence of paralysis of the muscular coat. Tremulousness 
affecting more especially the hands and tongue, is almost con- 
stantly observed in severe cases. General muscular tremors 
•occur in the aged and infirm, and in those who have been addicted 
to the too free use of intoxicating drinks. Ataxic symptoms, 
such as subsultus tendinum, spasmodic twitchings of the facial 
muscles, carphologia, and picking at the bed-clothes, are present 
to a greater or less degree in all severe cases. Nystagmus and 
obstinate hiccough occasionally occur. Tense contractions of 
the flexor muscles of the forearm, thighs and legs, are very rare, 
and occur only in grave cases. 

General convulsions are not often met with; but if they do 
appear, which is generally towards the end of the second week, 
life is seldom prolonged beyond three or four days. They are 
usually preceded by a tendency to stupor or to coma, and by a 
marked diminution in the quantity of urine, and are, as a rule, 
caused by uraemia. 

The Special Senses. — In the early days of the fever, the eyes 
are watery, the conjunctivae are deeply injected, and the pupils 
are contracted. Hardness of hearing, preceded by ringing noises 
in the ears, is very common after the middle of the' first week, 
and frequently extends into convalescence. Cutaneous hyperse- 
sthesia is a not uncommon symptom during the first week. 

The Temperature. — The temperature range in typhus fever 
(fig. 15), is shorter and rises more rapidly to the maximum, than 
■does that of typhoid fever. The fever increases rapidly from 
the onset of the disease, and the temperature observes very 
nearly the following formula of ascent: 

It reaches 103° Fahr. or 105° Fahr. on the first evening; on 
the next morning it recedes to between 98|° Fahr. and 103° 
Fahr.; on the second evening it rises up to or above 1045° Fahr,; 



TEMPERATURE RANGE. 



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'286 LECTURES ON FEVERS. 

on the third evening it often reaches 105° Fahr. or 106.5° Fahr. 
exceptionally it does not rise above 102° Fahr. ; and on the fourth 
evening it is rarely under 105.8° Fahr. and not infrequently it 
attains 107° Fahr. In children it may not at any time exceed 
103° Fahr. 

In mild or moderate cases, the maximum is reached on the 
fourth day, and at the close of the week there is a slight decrease 
of temperature. On the seventh, or eighth day, there is a more 
marked remission, followed on the ninth day, seldom later, by a 
rise of from 0.5° Fahr. to 3.5° Fahr., which lasts from one to 
three days, and then slowly subsides. A third remission, occu- 
pying a half day or two mornings, occurs about the twelfth day, 
and is followed by a third brief rise, which terminates in defer- 
vescence. 

In severe and neglected cases, the temperature continues to 
rise through the first week until it reaches 106° Fahr. or 107° 
Fahr. It remains persistent at 104° Fahr. in the morning, and 
at 105° Fahr. or 106° Fahr." in the evening, through the whole or 
a part of the second week. Cases which tend to recovery show 
a slight declination towards the end of the second week, and yet 
the high temperature continues during the third week. In these 
severe forms, the temperature range differs from that of typhoid 
fever in that the daily maxima are higher, and there is less tend- 
ency to remissions. 

The stage of defervescence in typhus occupies from twelve 
hours to two or three days, and is usually very characteristic. 
It is generally preceded by a short critical perturbation, a rise 
of from 0.2° Fahr. to 3.5° Fahr. above the preceding evening, 
and follows it in a precipitous or progressive descent. Occasion- 
ally there is no change in the temperature before the time of 
crisis, and when this is the case, the defervescence is very grad- 
ual. The critical defervescence usually appears between the 
thirteenth and seventeenth days, and the temperature sometimes 
falls in a single night from 104° Fahr. or higher to the normal. 
Recovery generally takes place after the crisis. During the first 
week of convalescence, the temperature often remains below the 
normal, especially in the morning. 

A very high range of temperature during the first week indi- 
cates severe cerebral symptoms during the second week. 



THE ERUPTION. 287 

The absence of a slight remission about the seventh or eighth 
day is an unfavorable omen. 

A sudden rise during the first week indicates the occurrence 
of complications. 

Fatal cases announce themselves at the outset, by an enormous 
height of temperature, 106° Fahr., or more. 

Just before death and in the death agony, the temperature 
rises from 2° Fahr. to 6.5° Fahr. 

The Pulse. — In the beginning of an attack the pulse is usu- 
ally full, soft and compressible. As the disease progresses it 
diminishes in force and rises in frequency. It ranges from 110 
to 130 beats per minute. On the third day, in mild cases, it sel- 
dom exceeds 100, while in severe cases it may reach 120 or 130. 
In unfavorable cases it may run up to 140 or even 150 per min- 
ute. A pulse which remains for three consecutive days, above 
120 per minute, is a bad omen. During the first week, the pulse- 
rate and the temperature-range, usually correspond, but after 
this time the parallelism ceases. During the second week, es- 
pecially if the debility is very great, the pulse may become more 
rapid as the temperature falls ; or the pulse may at other times 
diminish in frequency, and yet the temperature rise. A rapid 
fall in the pulse rate during defervescence is usually a favorable 
indication. A decided rise after it has fallen is frequently indi- 
cative of pulmonary complications. 

The heart impulse is almost invariably enfeebled, after the 
fifth or sixth day of the fever, and the cardiac first sound is oc- 
casionally replaced by a soft systolic murmur. As convalescence 
becomes established both the impulse and the first sound slowly 
return to normal. 

The Eruption. — The eruption of typhus fever, which is very 
rarely absent, appears, as a rule, on the fourth or fifth day. It 
is preceded and accompanied by an erythematous redness of the 
whole surface, and is first seen upon the sides of the chest and 
abdomen. It consists of a mottling or marbling of the skin, 
described as the sub-cut icular rash, and of pale, dirty pink, or 
florid spots, slightly raised above the surface, disappearing on 
pressure, and presenting by their grouping, a close resemblance 
to measles. After two or three days they are no longer elevated 
and distinct, but frequently appear as illy-defined rust-colored 



288 LECTURES ON FEVERS. 

stains, which are but slightly influenced by pressure. The sub- 
cuticular mottlings gradually disappear as the spots grow darker. 
The latter are generally darker and more distinct on the depend- 
ent portions of the body. The extent and lividity of the eruption 
are, usually, proportionate to the severity of the attack. 

During the second week, the centers of some of the pigmented 
spots, become the sites of minute extravasations of blood. In 
some cases true petechia appear; they are, however, seldom 
present before the last stages. After death the petechia and the 
rusty stains remain persistent, but the pinkish or florid spots 
usually disappear. 

The duration of the rash, which generally disappears with 
defervescence, is from eight to twelve days. 

Minute transparent vesicles, called suclamina, have been ob- 
served in a limited number of cases, at a late period of the dis- 
ease. Urticaria, herpes and erysipelas, exceptionally occur. 
Changes in the nails, as shown by white bands and furrows, in- 
dicating arrest of nutrition during the fever, not infrequently 
take place. Slight, bran-like desquamation, proceeding from 
above downward, occasionally occurs, during convalescence. 

Emaciation is seldom marked, and is rarely present before 
the third week. 

The ammoniacal or " mouse-like " odor, which emanates from 
typhus patients is said to be characteristic. 

The Respiratory System. — During the first week the respira- 
tions rarely exceed twenty or thirty per minute. But during the 
second week, with the advent of delirium, they become hurried, 
and range from forty to fifty per minute. In grave cases, when 
the prostration is extreme, and the stupor becomes profound, 
they are irregular and sometimes fall to eight or ten per minute. 

Nasal and bronchial catarrh attended with slight cough, is 
usually present during the first week. Diffuse bronchitis, hy- 
postatic congestion of the lungs, or lobular pneumonia may 
appear during the second week. Diphtheritic croup has been 
observed in some epidemics. 

The Digestive System. — The changes in the digestive tract 
are mainly functional in character. Nausea and vomiting are 
rare. Vomiting occurs as an early symptom, principally in dys- 
peptic individuals ; occurring after the first week, it is occasion- 
ally the precursor of ursemic convulsions and coma. 



MORBID ANATOMY. 289 

At first the tongue is covered with a whitish or yellowish-white 
fur. Towards the end of the first week, it becomes dry and 
brown arid is protruded tremulously. Ts T ot unfrequently, in severe 
cases, it becomes dry and crusted, and is firmly retracted into a 
globular mass. In grave cases, about the beginning of the sec- 
ond week, sordes collect upon the gums, teeth and lips. 

Thirst and anorexia are constant symptoms. The former is 
most marked during the first but diminishes during the second 
week. The latter is complete throughout the attack, but disap- 
pears, often suddenly, during the sleep that marks the crisis. 

Constipation is the rule. A mild, dark, greenish-brown diar- 
rhea sometimes occurs at the period of critical defervescence. 
Involuntary discharges occur only in severe cases, and generally 
upon the approach of death. Acute enlargement of the spleen 
is frequently present. 

The Urine. — At first the urine is diminished in quantity, and 
is high-colored and of high specific gravity. It is acid in reac- 
tion, and contains more urea and less chlorides. A small amount 
of albumen is frequently present early in the attack, and in se- 
vere cases it may be copious and persistent. Renal epithelium, 
and epithelial and fatty casts are not uncommon. Later in the 
disease the urine may become suppressed, and urinary retention 
may render the use of the catheter necessary. 

As convalescence approaches it becomes pale and increased in 
quantity. The chlorides reappear, the amount of urea lessens, 
and the albumen gradually disappears. 

Morbid Anatomy. — Typhus fever has no known special and 
characteristic lesion. Morbid appearances in different organs 
are frequently found after death, but they are due to the pro- 
longed, intense pyrexia, or to complications. 

The body is seldom very much emaciated, unless death has 
taken place after the second week. Cadaveric rigidity is usually 
of short duration ; and decomposition takes place rapidly. 

The blood is darker than normal. When drawn from the body 
it coagulates imperfectly and rapidly undergoes ammoniacal de- 
composition. The fibrin is diminished, while urea and ammonia 
are in excess. The red globules become diminished in quantity, 
and when examined under the microscope, many of them pre- 



290 LECTURES ON FEVERS. 

sent serrated edges, and some are found to have undergone de- 
generation. 

The heart undergoes granular degenerative changes, propor- 
tionate to the intensity and duration of the febrile movement. It 
is soft and flaccid; the muscular tissue is of a yellowish-brown 
color, and easily torn. The feebleness of heart-impulse is pro- 
portionate to the degree of degeneration found after death. 
Thrombi are often discovered in the superficial veins of the lower 
limbs. They are usually formed by a slowing of the general 
circulation, consequent upon the great feebleness of heart power, 
and are apt to cause swelling of one or both extremities. 

The kidneys are commonly hypersemic, and are apt to be en- 
larged in consequence of a cloudy swelling of the epithelium of 
the renal tubes. 

The liver and spleen, are, as a rule, enlarged. The former is 
hypersemic during the first, and more or less fatty and friable 
during the second week. The latter undergoes softening, early 
in the disease, even during the first week, and interstitial extrava- 
sations of blood, not infrequently occur. 

The respiratory tract exhibits signs of catarrhal inflammation 
of the bronchial tubes. Patches of atelectasis are often found 
as a result of capillary bronchitis. Evidences of hypostatic 
congestion, of catarrhal pneumonia, of pulmonary oedema or of 
pulmonary gangrene, are also frequently observed. 

The brain, as a rule, presents some changes. The cerebral 
vessels will be found to be intensely congested, or else an abun- 
dant, usually clear, fluid effusion, varying in quantity from one 
to eight ounces, will be observed underneath the arachnoid and 
in the ventricular cavities. 

Enlargement of the sub-lingual and parotid glands, is a not 
infrequent autopsic phenomenon. 



LECTUEE XIX. 

TypllllS Fever (Continued.) 

I will direct your attention to-clay to the differential diagnosis 
and treatment of typhus fever. 

Differential Diagnosis.— The diagnosis of this disease can- 
not be definitely determined before the appearance of the erup- 
tion. During the prevalence of an epidemic, the sudden onset 
of fever, after a short, sharp, sudden chill, with a rapid rise in 
temperature, dull, heavy, steadily increasing frontal headache, 
pain in the back and limbs, and early and extreme prostration 
are markedly suggestive typhus symptoms. The "mulberry 
rash " on the fifth or sixth day, and the critical defervescence 
about the fourteenth day are characteristic. 

The diseases with which it is most liable to be confounded are, 
typhoid fever, relapsing fever, cerebro-spinal fever, measles, 
pneumonia, acute Bright's disease, delirium tremens, remittent 
fever, pyaemia and the plague. 

The rules for differentiating typhoid fever and relapsing fever 
(p. 166), and cerebro-spinal fever (p. 236), I have already given 
you in the lectures upon those diseases. 

Measles as distinguished from typhus fever, in children, is 
characterized by the coryza and cough of the pre-eruptive stage, 
by the intensely injected pharyngeal mucous membrane, by the 
brighter tint of the eruption, by the presence of the eruption 
upon the face, and by the absence of nervous symptoms such as 
delirium, prostration and a tendency to coma. 

Pneumonia, with typhoid symptoms, is sometimes mistaken 
for typhus fever. If there is no eruption present, the appear- 

(291) 



292 LECTURES ON FEVERS. 

ance of the physical signs of pulmonic consolidation, is sug- 
gestive of pneumonia; for pulmonary consolidation as a compli- 
cation of typhus is not developed until after the sixth day of the 
fever, at which time the eruption is generally visible. 

Acute Bright s disease, which at times closely resembles ty- 
phus fever, may be differentiated by the lower temperature range, 
by the presence of oedema, and by the absence of the typhus 
rash. 

Delirium tremens, occasionally, closely resembles typhus. It 
differs however, in that it is generally marked by a lower range of 
temperature — seldom above 100° Fahr. — and by the absence of 
eruption. As a rule it is ushered in by insomnia instead of head- 
ache, and under circumstances which establish beyond a doubt 
the nature of the attack. 

Remittent fever, especially that malignant form which prevails 
in tropical countries, is attended by many symptoms of typhus. 
It, however, lacks the eruption of typhus, and is apt to be asso- 
ciated with other malarial types of disease. It is always attended 
by a greater enlargement of the spleen. 

Pyaemia, septicaemia and erysipelas are often attended by 
many of the ushering-in symptoms of typhus, and when the 
latter is epidemic, it will be frequently impossible to make a 
differential diagnosis until after the time for the typhus erup- 
tion. 

The plague resembles typhus in that it is highly contagious, 
and is attended with marked cerebral and petechial symptoms. It, 
however, differs from it by running a shorter course, and by being 
attended by nausea, vomiting and swelling of the inguinal and 
axillary glands. 

Prognosis. — The prognosis is always grave. It is, as a rule, 
more favorable in childhood and youth than in old age. It is 
particularly unfavorable in intemperate persons, and in individ- 
uals of a gouty diathesis. 

The ratio of mortality varies from six to fifteen or twenty per 
cent. 

Severe headache, early and extreme prostration, a presenti- 
ment of death, long- continued high temperature, constant delir- 
ium, profound stupor, " pin-hole pupil," " coma vigil" subsultus 
tendinum, carphologia, a cojnous eruption and a feeble heart 
impulse, are important danger symptoms. The danger is gen- 



TREATMENT. 293 

erally proportionate to the copiousness of the eruption, and to 
the severity and early appearance of the cerebral symptoms. 

The first indication of recovery, which usually appears between 
the tenth and the fourteenth days, is a diminution in the fre- 
quency of the pulse, accompanied by a fall of two or three de- 
grees in the temperature. 

Death commonly occurs about the crisis, but may take place 
at any period. It may occur by either asthenia or coma, but is 
generally due to complications. 

Treatment. — Prophylaxis. — Typhus fever is, in this country, 
almost exclusively, an imported disease. And its epidemics can, 
in the majority of cases, be traced directly to the introduction of 
the disease through infected Irish emigrants who land in New 
York and other large cities. Hence the responsibility of its occur- 
rence and spread, rests entirely with the national authorities. 
Much can, however, be done to prevent its spread after it is im- 
ported, and, as guardians of the public health, this will be a 
part of your duty. 

Upon an outbreak of an epidemic of typhus, the strictest san- 
itary measures should be observed, and more especially in local- 
ities where there is over-crowding, destitution and want. The 
first cases of the fever should be isolated in hospitals, and the 
dwellings in which it has broken out should be depopulated and 
thoroughly disinfected for one or two days, before the rooms are 
again inhabited. All typhus localities should be immediately 
quarantined. 

There is no known prophylactic treatment for typhus, other 
than isolation, free ventilation, and thorough disinfection of 
•everything contaminated by contagion. Fresh air is absolutely 
necessary. All the windows in the sick room should be kept 
open, regardless of the cold, and if necessary, the patients may 
be covered with blankets to keep them warm. In hospital prac- 
tice it has been found that patients do better in open tents, than 
when breathing the confined air of hospital wards. Cleanliness 
is of the utmost importance; all the excretions should be 
promptly and thoroughly disinfected with Piatt's chlorides, or a 
solution of carbolic acid. 

During typhus epidemics you should never visit a typhus pa- 
tient until after eating, and before the system has become fa- 
tigued by the worry and care of the dav's business. Always 



294 LECTUKES ON FEYEES, 

make your visits short, avoid inhaling the exhalations from the 
patient's body, and remember that the contagious distance is 
about two feet. 

After recovery or death, all articles worn by the patient, the 
room and all its contents should be thoroughly disinfected by 
the burning of sulphur or the pouring of crude carbolic acid on 
chloride of lime. The bed and body linen, and all blankets and 
flannels that have been about the bed, should, after exposure to 
the disinfecting gases, or immersion in some disinfecting fluid, 
be thoroughly boiled or baked. Carpets, if they have been per- 
mitted in the sick room, should be taken up and fumigated, and 
afterwards beaten or shaken, and exposed to the wind and sun- 
shine in the open air for several days. The mattrass and pillows 
should be burned. After everything has been disinfected, the 
wood-work of the infected building should be thoroughly cleaned 
with carbolized water ( one part of acid to forty or sixty of water), 
the walls whitewashed, and the rooms freely aired for at least 
one week. 

Principal Remedies. — Gelsemium is indicated when the fever 
sets in suddenly, after over mental exertion, and when there is 
great prostration of all the vital forces. Baptisia will be of 
service early in the disease, when there is intense headache, with 
extreme depression of vitality, and despair of cure. Bryonia is 
called for during the first week, when there is a dry cough, with 
throbbing or darting, tearing pains in the head, aggravated by 
motion, 'or with mild delirium about business affairs. 

Belladonna when there is great cerebral congestion with throb- 
bing of the carotids, or furious delirium. Hyoscyamns when 
the cerebral symptoms are more adynamic, and the patient sinks 
into a state of apathy and stupefaction. It is one of the best 
remedies, when the pains in the head are very severe, or when 
with the delirium there is a constant desire to escape. Also if 
there is a good deal of mucous rale. Stramonium will be of 
service when the delirium is so excessive as to threaten exhaus- 
tion. Agaricus is called for when ataxic symptoms are present, 
and when with tremor and restlessness there is a constant desire 
to get out of bed. Phosphoric acid when there is great nervous 
depression with slight febrile excitement. Opium if wild delir- 
ium alternates with stupor and stertorous breathing, or if sopor 



LEADING INDICATIONS. 295 

threatens to terminate in paralysis of the brain. Arnica if stu- 
pefaction is attended with involuntary discharge of stool and 
urine. Rhus tox. for involuntary foetid evacuations, with an 
accumulation of blackish-brown mucus on the tongue. Arseni- 
cum alb. for urierhic convulsions, and when with involuntary 
diarrhea there are a sunken countenance and a dry, cracked 
tongue. Opium for ursemic coma, and for urinary retention. 
Muriatic acid in advanced stages, when there is complete loss 
of muscular power, and low delirium; the patient is so weak he 
settles down in bed. 

Merc, bi-jod. is the remedy for inflammatory swelling of the 
salivary glands a ad areolar tissue about the neck. Senega or 
tart, emet, for the bronchitis. Phosphorus for lung complica- 
tions and when there is extreme nervous depression. If gan- 
grene threatens, either arsenicum or carbo. veg. will be needed. 
And when there is sudden sinking of the vital forces, with apa- 
thy, muttering delirium, and an intermittent pulse, veratrum alb. 
may do you excellent service. 

Leading Indications. — The guiding symptoms for these and 
other remedies of use in typhus, may be compiled as follows: 

Aconite. — Great fear of death; he predicts the day he will 
die (ars. ). Sensation of emptiness in the head (cocculus). Full- 
ness and heaviness in the forehead, as if the brain would start 
out of the eyes (bell, bry.). Burning headache, as if the brain 
were moved by boiling water. Active inflammatory symptoms. 
In sanguine and plethoric individuals. 

Agaricus lnnsc. — Disinclination to answer questions (phos. 
acid). Desire for alcoholic drinks. Sensitive smell (colch.). 
Dry tongue with dryness and constriction in the fauces. Rumb- 
ling in the bowels with the passage of much inodorous flatus. 
Delirium with constant raving, tries to get out of bed (hyos.). 
Contracted pupils; dry, tremulous tongue. Frequent pulse, 
with weakness of the first sound of the heart. Trembling of the 
hands. Pains in the legs, especially in the hip joints. Twitch- 
ings of the gluteal muscles. Cramps of the hands and feet. 

Apis mel. — Stupor with muttering delirium. Sopor, inter- 
rupted by piercing shrieks. Tongue swollen, dry, cracked, ul- 
cerated and protruded with difficulty (ars., rhus). Great sore- 
ness in the pit of the stomach when touched (bry.). Soreness 



296 LECTURES ON FEVERS. 

and bloatedness of the abdomen (lack.). Frequent, foul, invol- 
untary stools. Suppression of urine (hyos., opium). White 
miliary eruption on the chest and abdomen. Great weakness 
and sliding down in bed (mur. acid). Carbuncles with burning, 
stinging pains (ars.). Accumulation of tough mucus in the 
throat. 

Arnica. — Stupefaction with foetid breath, and large, yellowish- 
green spots on the skin. Great weariness compelling the patient 
to lie down, and yet he asserts that he feels perfectly well {ars. ). 
Forgets the words while speaking (rhus). Declines to answer 
questions (phos. acid). Confused feeling in the head with pres- 
sure over the right brow. Unrefreshing sleep with anxious 
dreams. Muttering and loud blowing during expiration. Desires 
to be constantly moved, the bed feels too hard (bapt). Dryness 
of the lips and tongue. Trembling of the lower lip. Brown 
streak through the center of the tongue (bapt). Involuntary 
discharge of urine and faeces (ars., hyos.). Petechias. Ecchy- 
moses. 

Arsenicum alb. — Great restlessness and anxiety. Predicts 
the day he will die (aconite). Constant motion of the head and 
limbs. Death-like color of the face (carbo. veg.). Sunken, hip- 
pocratic countenance (verat alb.), Staring, glistening, sunken 
eyes. Hardness of hearing. Lips dry, cracked and covered 
with sordes. Tongue red, dry and cracked (bry., rhus). Black, 
leather-like tongue. Dryness of the mouth with violent thirst; 
drinks often, but little at a time (bell., cinch., opp. bry.). Unin- 
telligible articulation, as if the tongue was too heavy (carbo.veg.). 
Intense burning pains in the stomach and pit of the stomach 
(phos., verat. alb.). Violent and incessant vomiting. Involun- 
tary micturition ( hyos. ). Weak, tremulous, hoarse voice. Short, 
anxious, rattling breathing, with great anguish. Very tenacious 
mucus in the chest (kali bich., tart. emet. ). Extensive pulmonary 
hypostasis. Pulse frequent, hard and tense, or small, trembling 
and intermittent. Irregular action of the heart, absence of the 
second sound. White miliary eruption (lach., mur. acid). Pe- 
techias (rhus, secale, am.). Boils (mere, sil., sul.). Carbuncles, 
which burn like fire ( canst, mere, sil). Bapid prostration of 
strength (aconite, verat. alb.). 

Arum triph.— Soreness of the lips and corners of the mouth. 



LEADING INDICATIONS. 297 

Swelling of the sub-maxillary glands and neck (mere, bi-jod.). 
Sore, red tongue with elevated papillae. Foetid breath. Boring 
of the nose, picking the ends of the fingers. Symptoms of 
uraemic poisoning (ars., opium). 

Baptisia. — Confusion of ideas (gels., rhus). Great nervous 
restlessness, especially at night. Dull, stupefying headache 
(gels. ). Head feels as if scattered about; tries to get the pieces 
together (sir am.). Falls asleep in the midst of attempted an- 
swers (am., hyos.). Dark, red face, with besotted expression. 
Numbness of the head and face. Tongue coated brown, and 
dry, particularly in the center. Feeling as if the lower limbs 
were severed from the body (opium). Sensation as of a second 
self alongside in bed. The hands feel too large. Soreness of 
the flesh, the bed on which he lies feels too hard (am., rhus). 
Offensive secretions. 

Belladonna. — Starting, jumping during sleep. Sleepiness, 
with inability to sleep (loch., opium). Violent delirium. Con- 
stant desire to spring out of bed (agar., hyos.). Attempts to 
bite, strike and spit at attendants (hyos., opium). Violent 
throbbing in the brain. Throbbing of the carotids (glon.), and 
great intolerance of light and noise (aco., opium). Pressive 
pain in the forehead, as from a heavy weight, obliging him to 
close the eyes (puis.). Sparkling, staring eyes (hyos., stram.). 
Dilated pupils (gels.). Humming, roaring and tingling in the 
ears. Glowing redness of the face, or else great paleness (bry.). 
Dryness of the mouth, tongue and throat. Tongue red at the 
edges and white in the center (gels.). Trembling and heaviness 
of the tongue with stammering speech (lach.). Difficult 
deglutition; fluids swallowed, return through the nose (kalibich., 
lach.). Involuntary micturition and defecation. Tendency to 
slide down to the foot of the bed (mur. acid). Dry, spasmodic 
cough, worse at night (dros., hyos.). Jerking of the bedclothes. 
Starts as if in affright on awaking or during sleep (ars.). 

Bryonia. — Exceedingly irritable, everything makes him angry 
(cham.) Nightly delirium, especially about the affairs of the 
previous day, or business matters. Desire to escape from bed 
and go home. Vertigo with sensation as of the head turning in 
a circle (bell). Visions when closing the eyes. Buzzing in the 
ears with hardness of hearing. Bed, bloated, hot face. Dry, 



298 LECTURES ON FEVERS. 

parched and cracked lips. Tongue dry. rough and cracked, often 
of a dark-brown color. White or yellow coating on tongue. Ex- 
cessive thirst, drinks laige quantities at a time, and at long in- 
tervals. Nausea and faintness on rising. Stitches in the liver 
and spleen (mere). Constipation. Cough, with stitches in the 
chest, and expectoration of tenacious, rust-colored sputa (jihos.-, 
rhus). Typhoid pneumonia. Restless sleep with moaning and 
with chewing motions (hell). Great weakness and exhaustion .. 

Camphor* — Sudden and great sinking of strength (ars), 
Extreme restlessness and anxiety (ars ). Cold sweat all over the 
body (verat. alb/). Cold, pointed nose. Face, pale and anxious* 
Sudden sinking spells. Small, weak scarcely perceptible pulse 
(carbo. veg). Violent delirium. Great thirst; coldness of the 
tongue (carbo. veg., verat. alb.). Battling in the throat, invol- 
untary evacuations. 

Carbo. veg.— Restlessness and anxiety. Greenish color, or 
great paleness of the face (ars ) Hippocratic countenance 
(verat. alb.). Coldness of the breath and tongue; at times the 
tongue is moist and sticky; at others it is dry and cracked. 
Hawking of mucus in the throat. Internal burning, wants to be 
fanned (ars.), Loud, rattling breathing. Cough, with greenish, 
foetid expectoration (sil ). Paralysis of the lungs with blueness 
of the face, lips and tongue. Thread-like ; scarcely perceptible 
pulse. Ecchymoses. 

Cinchona. — Sense of internal illness, as of impending disease. 
Pressure in the head from within outwards, as if it would burst, 
relieved by haid pressure. Whizzing in the ears, with hardness 
of hearing (phos., rhus). Bitter taste in the mouth; obstinate 
constipation. Empty eructations: milk deranges the stomach 
(sulph). Enlargement of the Jivei and spleen. Profuse sweat 
during sleep, especially on the side on which the patient lies. 
Great weakness. Protracted convalescence. 

CoccuhiS.— Slowness of comprehension. Vertigo with nausea 
when rising up in bed (bry ), must lie down. Heaviness of the 
lids, with unconquerable sleepiness. Drowsiness lapsing into 
coma. Stupor; coma vigil. Noise in the ears like the rushing 
of waters. Tremulousness; automatic motions. Weakness of 
the cervical muscles. Drink rolls audibly down the throat into 



LEADING INDICATIONS. 299 

the stomach (laur., hydr. acid). Great general weakness and 
weariness after over-exertion (agaricus). 

Gelseminm.— Dullness of the mental faculties (bapt ). Drow- 
siness, vertigo, and great muscular prostration. Heaviness of 
the head, relieved after profuse emission of watery urine (phos. 
acid). Vertigo and blurred vision (iris vers.). The brain 
feels as if bruised (bell.). Head feels as "big as a bushel," 
Cephalalgia with lancinating pains extending from the left oc- 
cipital region through the head to the forehead and eyeballs. 
Pain as from a tape around the head (mere, ), Drooping of the 
eyelids (rhus). Great aversion to light, with dilatation of the 
pupils (bell). Heavy, besotted expression (bapt.). Crimson 
flush of the face. Tongue coated yellowish-white, with foetid 
breath. The tongue trembles so he can hardly protrude it (bell., 
lack., secale). Predominance of nervous symptoms (johos.). 
Complete prostration of the whole nervous system (cimicifuga). 

Helleborus nig. — Sensation of soreness in the back of the 
head with stupefaction. Eyes vacant, pupils dilated ( bell., hyos.). 
Insensibility. Chewing motions of the jaws (bry.). Convulsive 
twitchings of the muscles (cupr. ). Constant picking of the lips 
and bedclothes. Sliding down in bed (mur. acid). Small, slow, 
tremulous pulse. Suppression of urine, or highly albuminous 
urine. Trifling loss of flesh, 

Hyoscyanms. — Complete loss of consciousness (bell, opium). 
Muttering with picking at the bedclothes (opium). Muttering 
loquacity (apis). Answers questions correctly, when asked, but 
lapses again into delirium (arnica, bell). Whines and dont 
know why. Coma vigiL Delirium continues while awake; sees 
persons who are not, and who were not present. Jumping out 
of bed. Thinks he is in the wrong place. Attempts to run 
away. Desires to uncover and remain naked. Flushed face, 
stupid expression (bapt). Red, sparkling, staring eyes (bell). 
Objects appear too large or red as fire (opp. plat.). Pupils di- 
lated (bell, opp. jihos.) and insensible (opium). Constrictive 
sensations in the throat with inability to swallow (bell, strain.). 
Clean, parched, dry tongue. Hiccough; putrid breath. Invol- 
untary stools at night (ars., rhus). Retention of urine (oj)ium). 
Involuntary urination. Grating of the teeth (apis, hell). 
Trembling of the limbs. Subsultus tendinum. Hyperesthesia. 



300 LECTURES ON FEVERS. 

of the skin. Brown spots, or gangrenous vesicles on the body. 
Great nervous excitability without much cerebral hyperemia. 

Lachesis. — Great mental and physical exhaustion. Sleepi- 
ness, with inability to sleep. Aggravation of all the symptoms 
after sleep. Headache, mostly in the forehead with nausea and 
chilliness (puis.). Loquacious, constantly changing from one 
subject to another. Stupor and muttering delirium (apis). 
Sunken countenance. Dropping of the lower jaw (ly cop., opi- 
um). Dry, red or black, cracked and bleeding tongue (ars.). 
Trembling of the tongue when protruding it (bell., gels.). In 
putting the tongue out it catches on the teeth or under lip. Dry, 
cracked and bleeding lips. Variable appetite. Desire for oys- 
ters (lye.). Hyperesthesia of the abdomen. Alternate diarrhea 
and constipation. Dyspnoea. Hawking of mucus with rawness 
in the throat. Burning in the chest (opp. ars. ). Irregularity 
of heart-beat (digit.). Carbuncles surrounded by small boils 
and purple spots. Falling off of the hair (mere., ptlios.). In 
intemperate persons. 

Lycopodium. — Depression of spirits (not,, puis.). Afraid of 
being alone (ars.. opp. mix). Uses wrong words to express an 
idea (am., anac., graph.), Kestless sleep. Pressing headache 
on the vertex, worse from lying down. Tearing pain in the oc- 
ciput (con.). Putrid smell from the mouth. Roaring, humming 
and whizzing in the ears (cinch.). Tongue coated white, or else 
red and dry Yesicles on the tongue. The tongue is thrust 
spasmodically to and fro between the teeth. Dropping of the 
lower jaw (lach., mur, acid, opium). Fan-like motion of the 
alee nasi. Desire for sweet things. A little food seems to fill 
the stomach full, and causes fullness and distension of the abdo- 
men. The urine leaves a red, sandy stain on the sheet (cinch., 
phos<). Chilliness in the rectum before stool. Scanty stool 
with a sensation as if much remained behind. The hair becomes 
gray early. Falling out of the hair (graph., mere, phos.). 

Mercurius. — Great restlessness, weariness and prostration. 
Heaviness of the head with great inclination to sleep. Swollen, 
soft, flabby tongue, taking the imprints of the teeth. Putrid 
odor from the mouth. The tongue is coated with a dirty-yellow 
fur: feels as if burnt (colocynth). Region of the liver painful 
and sensitive to contact (bell, bry.). Swelling and suppuration 



LEADING INDICATIONS. 301 

of the inguinal glands (nit acid). Frequent urination, the 
urine leaves a whitish sediment. Icteroid hue of the skin. Su- 
daniina. 

Muriatic acid. — AYhen decomposition of the fluids is slow 
and extensive. Continuous delirium; vivid hallucinations. The 
patient is busied with past and present events. Sleepiness in 
the daytime, sleeplessness at night with muttering delirium. 
Constant inclination to slide down in bed. Glistening eyes; 
contracted pupils. Acuteness of the special senses. Excessive 
dryness of the lips, mouth and tongue. Tongue heavy, like lead, 
preventing talking. The lower jaw hangs down (loch,, lycop., 
opium). Id voluntary micturition and defecation. Pulse rapid 
and very feeble, intermits every third beat (nit acid). Acceler- 
ated breathing. Great prostration. 

Nux vom. — Over-sensitiveness to external impressions (cinch.). 
Delirious phantasies only on lying down. Chilliness on slight 
movement. Dryness of the mouth and tip of the tongue. Hun- 
ger with aversion to food (opium). Flatulent distension of the 
abdomen after eating (cinch.. lycop.). Alternate constipation 
and diarrhea. Throbbing in the region of the liver (hry.). 
Numbness and deadness of the lower limbs. Heaviness of the 
body (opp. sepia). In thin, slender persons. 

Opium. — Drowsiness or sopor. Complete loss of conscious- 
ness (hyos. ) with slow stertorious breathing. Symptoms resemb- 
ling delirium tremens. Stupid sleeplessness with frightful 
visions. Suffocating nightmare. Muttering delirium. Attempts 
to escape (bell., hyos.). Contracted pupils (hyos., physostigma). 
Glassy, half-closed eyes. Face dark-red, bloated, hot (bell.) 
flushed (hips ), or pale and sunken. Bed feels hot, can hardly 
lie on it. Difficult, intermitting breathing, as from paralysis of 
the lungs (lye, tart. emet). Deep snoring, slow breathing with 
open mouth. Convulsive movements and numbness of the limbs. 
Retention of urine. Involuntary stools. Picking at the bed- 
clothes (hyos.). Dropping of the lower jaw (lack., mur. acid). 
In children and old people. 

Phosphorus. — Constant sleepiness. Low muttering delirium 
(arn.,bapt. rhus). Coma vigil. Inability to concentrate thought 
(am, rhus). Carphologia (am., hyos.). Contracted pupils. 
(opium, physostigma). Humming and roaring in the head. 



302 LECTURES ON FEVERS. 

Throbbing in the ears (calc), loud whizzing before the ears 
(mere). Dullness of hearing, particularly of the human voice. 
Pale, sallow complexion. Dry, immovable tongue, cracked and 
covered with sordes (ars., verat. alb.). Thirst with desire for 
very cold drinks (rhus). Region of stomach painful to touch. 
Feeling of coldness in the abdomen (ars., sepia). Brown urine, 
depositing a brick-dust sediment (cinch., lye. ). Hard, dry cough 
with oppression of the chest. Loud mucous rales in the lower 
lobes (ipecac, tart emet). Hepatization of the lungs. Small, 
quick, easily compressed pulse. Heaviness of the lower limbs. 
Ecchymoses. 

Phosphoric acid.— Perfect indifference (cinch., lye). Disin- 
clination to talk (bell, phos., opp. siram.). Incapacity for 
thought (gels.). Answers questions slowly and reluctantly or 
short and incorrectly (phos.), Somnolence with muttering de- 
lirium. Headache, worse from the least shaking or noise (bell., 
kali bich). Deafness with roaring in the ears. Dryness of the 
tongue and throat without thirst (nux). Desire for refreshing 
or juicy things (puis., verat. alb,). Feeling of heaviness in the 
region of the liver. Involuntary stools. Frequent emission of 
pale, watery urine, forming a milky-white cloud, especially at 
night. Frequent, small, feeble pulse. Cough with purulent, 
offensive expectoration (ars., sulph.). Bluish-red spots on the 
parts upon which the patient lies. Profuse night (mere) and 
morning (cinch.) sweats. In young persons who have grown 
very rapidly, 

Rhus tox. — Great restlessness and uneasiness (ars.)- Inco- 
herent muttering. Answers questions correctly but slowly (bry.. 
hepar), Desire to commit suicide (hepar, mix). Active delir- 
ium and great prostration. Vivid, troublesome dreams of exces- 
sive bodily exertion. Fullness and heaviness in the forehead, 
worse from opening or moving the eyes (puis.). Dark, livid 
redness of the cheeks. Dry, red, cracked tongue (bapt, bell). 
Redness of the tip of the tongue in the shape of a triangle. 
Putrid taste and breath. Induration of the parotid and sub- 
maxillary glands. Great thirst for cold drinks (j)hos. ) especially 
cold milk. Involuntary fetid stools during sleep. Dry, tickling 
cough, worse in the evening and before midnight. Infiltration 
of the lower lobes of the lungs. Erysipelas with great burning. 
Glandular swellings. 



LEADING INDICATIONS. 303 

Secale corn. — Constant sighing. Great prostration and ex- 
treme restlessness. Mania with inclination to bite (bell, stram.). 
Aversion to being covered. Anxiety and burning at the pit of 
the stomach (ai*s.). Fear of death (ars.). Cold perspiration 
on the face and forehead. Brown or blackish tongue (ars.). 
Violent, unquenchable thirst. Hiccough (ars. } nux mos.). In- 
voluntary diarrhea (hyos.). Suppression of urine. Great trem- 
bling when attempting to move. Fuzzy feeling in the extremities. 
Extensive ecchymoses. 

Stramonium. — Stupid indifference (phos. acid). Desires 
light and company (opp, hyos.). Loquacious delirium (lack., 
lachnanthes). Furious delirium; strange fancies; and desire 
to go home (bry.). Indomitable rage, and desire to bite (bell., 
secede). Wide open, staring eyes (bell., hyos.). Transient loss 
of sight, hearing and speech. Oblique vision. Tiolent thirst, 
especially for sour drinks (bry., secede). Yellowish-brown coat- 
ing on the tongue which is dry in the center (bapt.). All food 
tastes like straw (sulpk. ). Black stools which smell like carrion 
(ars., carbo. veg.). Suppression of urine or else involuntary 
urination. Constant restlessness with jerking motions of the 
limbs and of the whole bod}*. Carphologia. Subsultus tendi- 
num. 

Sulphuric acid. — Irascibility. Hardness of hearing (Gala, 
sulph.). Dry, red or brown tongue. Aphthae. Swelling and 
inflammation of the sub-maxillary glands. Violent hiccough 
(secede). Dark, persistent hemorrhages. Blue, ecchymotic spots 
(carbo. veg., phos. aciel). Great weakness and prostration. 

Tartar emet. — Stupefying headache with pressure from with- 
out inwards, in the forehead and over the root of the nose. 
Irresistible inclination to sleep. White, pasty coating on the 
tongue. Tongue red in streaks and dry in the middle (rhus). 
Continuous anxious nausea (ipecac). Violent and painful urg- 
ing to urinate with scanty or bloody discharge ( can. sed. ). Great 
rattling of mucus in the chest (ipecac). Cough with suffocative 
attacks. Threatened oedema of the lungs (moschus). 

Teratruiu ail}.— Desire to bite, strike or tear things (bell 
sir a m.). Coma vigil with frequent starts, as if from fright. 
Sudden sinking of strength (ars., camph.), Hippocratic coun- 
tenance. Cold perspiration, especially on the forehead. Sunken 



304 LECTURES ON FEVERS. 

eyes; pointed nose. Tongue cold (carbo. veg.), or coated white 
with red tip and edges. Violent thirst for cold water (ars., phos.). 
Spasmodic constriction of the throat (hyos.). Suppression of 
urine. Icy coldness of the hands and feet. Petechia on the 
extremities, 

Veratrum vir. — Muttering delirium. Restless sleep, with 
dreams of being drowned. Headache, the pains begin in the 
forehead and run back to the occiput and spine. The eyes re- 
main open and the pupils are dilated. The face is flushed, or 
else pale and covered with cold perspiration. The tongue is 
coated white or yellow, with a red streak down the center. The 
pulse is irregular, hard and frequent, and the heart beats rapidly 
when turning over in bed (bell.). Oppression of the chest with 
slow, labored breathing. Involuntary .urination. Hiccough. 
Subsultus tendinum. Heart failure. 

Zincum. — Weakness of memory (anac). Brain exhaustion. 
Delirium, with attempts to get out of bed (hyos.). Constant 
jerking of the whole body during sleep. Carphologia. Subsul- 
tus tendinum. Sliding down in bed (mar. acid). Involuntary 
evacuations. 

HYGIENIC AND DIETETIC TREATMENT. 

The sick room should be large and well ventilated, for in ty- 
phus fever. bad air is more to be dreaded than ventilation. Al- 
huays allow plenty of fresh air to circulate about the patient, day 
and night. For asylums, the hospital tent will always be better 
than the hospital ward. 

Carpets, all unnecessary furniture, and everything that is liable 
to absorb and retain contagion should be removed from the 
apartment. The patient should go to bed as soon as the fever 
appears. All unnecessary visiting should be prohibited. All 
mental and bodily effort should be avoided. Throughout the 
whole course of the disease, quietude and the strictest cleanli- 
ness should be observed. Piatt's chlorides diluted one part to 
ten, or some other disinfectant, should be sprinkled freely over 
the bed and on the floor. Cloths wet in the solution should 
also be suspended in the room. In severe cases, especially after 
the first week, the patient must not under any circumstances be 
allowed *to assume the erect posture, as fatal syncope might re- 
sult. To prevent hypostatic pneumonia the nurse should be 



HYGIENIC AND DIETETIC TREATMENT. 305 

instructed to turn the patient upon one side or the other every 
few hours. 

The diet consists, principally of milk, which may be adminis- 
tered ice cold if desired. After three or four days, to support 
strength, beef tea, mutton broth, light soups, milk punch, or yolks 
of eggs beaten up iD milk, may be alternated with milk. The 
patient should be fed — not over-fed — as often as every two hours 
during the day, and every three hours during the night, except 
when quietly sleeping. Water may be administered without 
stint. When food is obstinately refused or cannot be swallowed, 
life may be sustained by pouring liquid nourishment into the 
stomach, by means of a long tube passed through the nose, or by 
rectal alimentation. The hypodermatic method of administering 
remedies (p, 98) will also be of service in such cases. 

Sponging the body every night with warm whisky and water 
is not only grateful to the patient, but is also useful as a sanitary 
measure. 

Concerning baths, which are deemed advisable unless adynamia 
is present, Loom is, who has had large experience with typhus in 
this country, writes: "As soon as the temperature of the patient 
rises to 104° Fahr. he must be placed in a bath, the temperature 
of which is about ten degrees below that of the patient; grad- 
ually, by the addition of ice or ice- water, bring the temperature 
of the bath down to 68° Fahr. or 70° Fahr. The patient must 
be kept in the bath until his temperature falls to 101° Fahr. or 
102° Fahr., then taken out, quickly dried and placed in bed. For 
some time after the removal from the bath, the axillary temper- 
ature will continue to fall, as the trunk parts with heat to the 
extremities. As soon as the temperature rises again to 104° 
Fahr. the patient must receive another bath. If the patient is 
suffering with intense pain in the head, or is actively delirious 
during the bath, ice-bags may often be applied to the head with 
benefit. 

" As soon as you have passed the first week of the disease, 
having kept the patient's temperature below 103° Fahr., usually 
it will not be necessary or advisable to continue the baths." 

The constipation of typhus may be relieved by the adminis- 
tration of enemata of strong, warm soap suds or of thin gruel. 

Stimulants are very generally required in typhus fever, after 
the fourth day. They are seldom needed before the appearance 



306 LECTURES ON FEVERS. 

of the eruption, and are most useful in the second week, espe- 
cially at the approach of the crisis. They should be given in 
cases of great prostration with low muttering delirium and a 
tendency to coma, and continued for several days, especially if 
under their administration, the patient becomes stronger and 
more rational. A copious, dark eruption with coldness of the 
extremities, calls for stimulants; while active delirium, head- 
ache, scanty urination, and intense heat of the cutaneous surface 
render their administration inadvisable. As in other fevers, the 
first sound of the heart and the character of the pulse are the 
best indications. 

No positive instructions can be given as regards the amount of 
stimulation required in each case. The quantity necessary va- 
ries from one ounce to ten or twelve ounces of brandy or whisky, 
daily administered in tablespoonful doses. It is rarely neces- 
sary to give more than eight ounces in twenty-four hours. Brandy, 
whisky and champagne are the best stimulants. Where steady 
stimulation is called for, a tablespoonful of brandy or whisky 
punch (prepared by putting two tablespoonfuls of brandy or 
whisky into a tumblerful of milk) may be given alternately with 
two tablespoonfuls of beef essence (p. 190) or of beef tea (p. 193), 
every two hours. 

Ale or porter may be allowed, if desired, during convalescence, 
in preference to other stimulants. 

Premature exposure, over-exertion and excessive eating should 
be carefully guarded against. 



LECTUBE XX. 

Relapsing Fever. 

I shall speak to-day concerning Relapsing fever, the second in 
our list of contagious fevers. 

Definition. — It may be defined as an acute, peculiar, conta- 
gious fever, occurring in the form of an epidemic, chiefly met 
with during seasons of scarcity and famine, due to the action of 
a specific poison, supposed to be a spirillar organism. It is char- 
acterized by a succession of febrile and non-febrile events, and 
consists of: 1. The primary paroxysm, marked by quick onset, 
commonly at sunset, with or without chills or rigor; frontal head- 
ache, arthritic and muscular pains; a coated tongue, thirst, ano- 
rexia and constipation; tenderness over the liver and spleen; 
high-colored urine ; high and persistent pyrexia ; a rapid but weak 
pulse; occasionally delirium; and a typical crisis on the fifth, sixth, 
or seventh day, almost invariably attended with copious perspir- 
ation. 2. An intermission when the patient, though extremely de- 
bilitated, feels perfectly well, and which, when a relapse super- 
venes, comes to an end in seven days. 3. A first relapse which is 
usually ushered in at noon, with or without a distinct chill; runs 
a course similar to that of the attack of invasion; and terminates 
by an abrupt crisis on or about the fifth clay. Convalescence, which 
is generally rapid, usually takes place upon the termination of the 
first relapse ; occasionally a second, and still more rarely a third or 
fourth relapse occurs. A fatal result is infrequent, but may 
happen in consequence of sudden syncope, hemorrhage, or from 
suppression of urine and coma. No constant specific lesions are 
found upon examination after death. One attack affords no im- 

(307) 



308 LECTURES ON FEVERS, 

munity from subsequent attacks. The duration varies from 
fourteen to twenty-six, or thirty-nine days. The period of incu- 
bation varies from five to seven days. 

Synonyms. — It is otherwise known as spirillum fever, and has 
been described by different writers as famine fever, five day fe- 
ver, seven day fever, short fever, bilious relapsing fever, hunger- 
pest, Gujerath sickness, contagious or jaundice fever, Silesian 
fever and Bombay fever. 

History. — Relapsing fever is by no means a new disease, as 
there are numerous evidences of its having existed from a very 
early period. Spittal referring to its antiquity, states that the 
epidemic described by Hippocrates as having occurred more 
than twenty centuries ago, in the island of Thasos, in the iEgean 
sea, off the coast of Roumelia, must have been relapsing fever. 
In modern times the disease has prevailed at different epochs, 
and was first clearly described by Dr. John Rutty, of Dublin, 
in 1739. 

Wide-spread epidemics of relapsing fever and typhus fever 
prevailed in Ireland and Scotland in 1817-19. 

Following a commercial crisis, they again broke out in Ireland, 
in the summer of 1826, and extended to England. For sixteen 
years thereafter, relapsing fever remained unobserved. 

An outbreak occurred in 1842, starting first on the east coast 
of the county of Fife, and extending over Scotland and England. 

The first epidemic occurred in this country — where relapsing 
fever is not indigenous — in 1844, and was directly traceable to 
the landing of two infected Irish female emigrants from a Liver- 
pool packet, at Philadelphia. 

Following the failure of the potato crop in 1846, an extensive 
epidemic started in Ireland, and extended all over the British 
Isles. About this time an epidemic, consisting partly o£ relaps- 
ing fever and partly of typhus fever, prevailed in upper Silesia. 

From 1847 to 1851 it appeared again in New York and Buffalo, 
and in several of the larger Canadian towns. 

During the summer of 1855, it prevailed among the British 
troops in the Crimea. 

Following the liberation of the serfs, it appeared in Russia, 
principally among the poorest and most destitute classes; first 



ETIOLOGY, 309 

at Odessa, in 1863, and then at St. Petersburg, in 1864, where it 
has prevailed ever since. 

In 1867, typhus fever and relapsing fever reappeared in Sile- 
sia, and extended in the following year to Germany. 

In 1869-70 it prevailed to a considerable extent in Philadel- 
phia, New York and other large cities of this country. Like the 
former epidemic it was directly traceable to importation through 
Irish and German emigrants. 

In the latter part of 1872, relapsing fever broke out in Berlin, 
and reappeared in 1878 and 1880. 

It prevailed in the Bombay Presidency, and in Northern and 
Western India, from 1877 to 1880. 

An extensive epidemic, occurring mostly among males, pre- 
vailed at Konigsberg, in 1879 and 1880. 

Nearly all the epidemics of relapsing fever have originated in 
Ireland, and have generally been associated with want and over- 
crowding. Central foci are supposed to exist in the Asiatic 
provinces between Russia and India. 

Etiology. — The causes of relapsing or spirillum fever, are of 
two kinds, viz., predisposing and exciting. 

1. The Predisposing Causes. — Age exerts a slight influence. 
Nearly one-third of all cases occur in early life, and about one- 
fourth occur between the ages of twenty and thirty years. After 
fifty years of age the disease is rarely observed. 

Occupation, except as it involves actual exposure, as is the case 
with hospital internes, physicians, nurses, etc., does not predis- 
pose to relapsing fever. 

Destitution and bodily fatigue play the most important part 
among the predisposing causes of the fever. The connection of 
spirillar infection with individual want is very marked. Failure 
of crops, or scanty food necessitated by hard times, has preceded 
almost every epidemic. Occasionally the disease has developed 
and spread among those who were well-to-do, and were well fed. 
But, as a rule, no great epidemic has ever arisen or spread to 
any considerable extent among a prosperous and well-fed people. 

Exposure to heat or wet, with or without excessive physical 
exertion, has been observed to have a special predisposing effect. 

Over-crowding exerts a powerful predisposing influence. In- 
fected localities are usually those limited districts where pauper 



310 LECTURES ON FEVERS. 

emigrants congregate, and where excessive over-crowding of 
apartments or of houses is the rule. 

2. The Exciting Cause. — Since the discovery by Otto Ober- 
meier, in 1868, of the constant presence of certain thin, thread- 
like, spiral fungi — spirochceti — in the blood of relapsing fever 
patients, the parasitic nature of the contagion and the possibil- 
ity of the existence of pathogenic bacteria have become almost 
positively established. These spiral filaments (fig. 6 ) named by 
Cohn, spirillum Obermeieri, in honor of their discoverer, are ex- 
ceedingly slender, seldom measuring more than 0.15 to 0.2 mm. 
in length, and 0.001 mm. in diameter. In them, we, in all prob- 
ability, have the infecting principle of relapsing fever, which 
admits of being conveyed from the sick to the healthy, and is 
capable, under favorable conditions, of undergoing development 
and indefinite reproduction. And yet, notwithstanding it is a 
generally accepted belief that the spirillum is the cause, and not 
simply an accompaniment of the disease, our present knowledge 
would not justify us in declaring any given case, not one of re- 
lapsing fever, because the fungal mycelia are not found during 
the stage of pyrexia. 

The question whether or not the spirillum alone and per se 
produces the fever, cannot be definitely answered until its pa- 
thogenic power after cultivation, as well as after simple isolation,, 
has been tested. Drs. Koch and Vandyke Carter have succeeded 
in producing relapsing fever in monkeys, by inoculation with fresh 
spirillar blood, but failed to produce infection with either non- 
spiriliar or desiccated blood. They also succeeded in their cul- 
ture experiments with infected serum, alone or after dilution 
with aqueous humor, outside of the human body, but found that 
the spirillum does not grow as freely as does the bacillus anthrn - 
cis. They have not as yet succeeded in producing the fever by 
inoculation with the cultivated spirillum, but their success in 
producing charbon or splenic fever, with the cultivated bacillus 
anthracis proves that diseases can be so produced, and destroys 
the theory, held by a few, that septic poisoning alone is the cause 
of pyrexia. 

True to its plant life, it is probable that the spirillum observes 
that periodical order of growth which belongs to the vegetable 
kingdom, and as a natural inference the periodic recurrence of 
fever, must be intimately associated with corresponding growth- 



ETIOLOGY. 311 

states of the parasitic organism. The maintenance of fever is 
strictly commensurate with sustained parasitic growth; and the 
sudden termination of fever is unquestionably related to cessa- 
tion of parasitic growth. Each apyretic interval is strictly the 
incubation period of the following febrile event. Some of the 
fatal and more serious results of spirillar infection are referable 
to the premature growth of spirochseti in the blood, causing in- 
creased liability to obstructions of the circulation. The death 
of the parasitic organisms is supposed to depend upon the de- 
gree of consistency of the blood. Spirillar filaments have been 
detected in hemorrhagic effusions and in the menses, but have 
not as yet been found in the saliva, sweat or urine. 

Direct importation is, at least in this country, the probable 
method of introduction of relapsing fever. The apparently in- 
dependent origin of some epidemics may be explained by con- 
sidering that with a return of the conditions adapted to their 
growth, the germs or "lasting spores" produced during previous 
illness, and remaining for a long time dormant in the earth or 
building, may become suddenly revivified. A purely spontaneous 
origin is, in these progressive times, absolutely inadmissible. 

As soon as relapsing fever has appeared in any locality, it not 
only spreads with great rapidity, but also tends to form pestilen- 
tial centers for itself, in districts inhabited by the poor. The 
contagion is only freely communicable by the atmosphere, as 
only those attendant upon the sick, or who visit them in their 
close, illy-ventilated quarters, or live in adjoining apartments or 
dwellings, are liable to take the fever. The probable channels 
of infection are, the breath and the cutaneous transpiration of 
the sick. Impure drinking water is believed by some to be an 
important carrier of the infecting principle. 

The role of fomiies has not as yet been clearly ascertained. 
In some epidemics, especially in this country, the laundry wo- 
men in hospitals were never affected by the fever, while in others, 
particularly in Ireland, they contracted the disease without di- 
rect contact with the sick. Exceptionally the disease has been 
transported to a distance by infected clothing. Sleeping on 
empty ward-cots, previously occupied by persons sick with re- 
lapsing fever, has frequently led to the illness. 

By the inoculation of fresh febrile blood, on healthy men, the 



312 LECTURES ON FEVERS. 

incubation period has been ascertained to be not less than five, 
nor more than eight days. 

One attack affords no immunity from subsequent attacks. In 
Ireland, Russia, India and Egypt, the social conditions and rela- 
tions of the pauper population are such as to render the disease 
practically endemic within certain areas. 

From this brief review of the etiology of relapsing fever, we 
are led to the following conclusions: 

1. That it is due to a specific poison, probably the spirillum 
Obermeieri. 

2. That the poison is communicated from the sick to the 
healthy, solely by actual contact with the personal exhalations 
of the patient. 

3. That the disease is communicable during its successive 
febrile manifestations, and also for a short time both preceding 
and following the earliest of these. 

4. That, while famine, over- crowding and bad ventilation fa- 
vor its spread and increase its severity, they never originate it. 

5. That the poison passes into the system mainly through the 
respired air. 

6. That a prompt re-infection is possible, no immunity being 
conferred by a first attack. 

Forms. — Relapsing fever may be arranged, according as the 
fever does or does not return, into two main forms: 

1. The Abortive Form, characterized by a single febrile attack 
— common in the lower animals, but uncommon in man. 

2. The Recurrent or Ordinary Form, with one relapse — most 
frequently seen; with tivo relapses — less frequent; with three 
relapses — rare; with four relapses — very rare. 

Clinical History. — The clinical history of the ordinary form, 
embraces a description of the invasion attack or primary par- 
oxysm, the first non-febrile interval or stage of intermission, the 
second attack or relapse, and convalescence. 

The Primary Paroxysm. — Prodromes are seldom recognized, 
as the onset of the disease is usually abrupt. Commonly about 
sunset the patient is seized with a high fever, ushered in by a 
severe rigor or by a distinct chill. Accompanying the chill there 
are severe headache (usually frontal), pains in the spine and 
limbs, nausea and, not infrequently, greenish vomiting with a 



CLINICAL HISTORY. 313 

sense of weakness and indisposition for exertion. The temper- 
ature rises rapidly, and may reach 104° Fahr. m the morning 
and 105° Fahr. in the afternoon of the first day. During the 
two or three days following there is but little variation, the acme 
being frequently reached during the first twenty-four hours. 
The pulse is soft and compressible; like the temperature it in- 
creases rapidly, and may vary from 110 or 120 to 140 or even 160 
per minute within the first twenty-four hours. The eyes be- 
come injected early; the tongue is white and moist, occasionally 
if there is a typhoid tendency it becomes dry. The bowels are 
constipated; thirst is considerable. 

As the disease progresses, the pains in the back and extremi- 
ties increase in intensity, and are stabbing and lancinating in 
character. They extend to all parts of the body, but are most 
severe in the calves of the legs. Sleeplessness, as a result of 
the muscular pain is a frequent and distressing symptom. The 
mind usually remains undisturbed; occasionally active delirium 
occurs. The liver and spleen become large and tender, after the 
second day, and there is more or less delirium. The urine is 
scanty, shows a sp. gr. of 1015 to 1017, is acid in reaction, de- 
ficient in chlorides, and contains no albumen; when jaundice is 
present, it contains bile pigment. 

In the evening or during the night of the sixth or seventh day, 
after a brief augmentation of all the symptoms, a remission sud- 
denly occurs, attended by a profuse perspiration. The temper- 
ature falls 5°, 7° or even 10°, so that in the morning the body- 
heat may be below the normal standard. The pulse declines, 
but becomes small and feeble. The number of respirations also 
diminishes, and the breathing approaches the normal. The 
headache, the muscle pains and the abdominal uneasiness sub- 
side. The tongue speedily cleans, the appetite returns, and the 
jaundice begins to fade. The spirilla observed in the blood 
during the paroxysm have now disappeared. And, excepting a 
sense of weakness, the patient, who but yesterday was watched 
with great anxiety and alarm, now regards himself well. He 
has, however, only entered upon the stage of intermission. 

The Stage of Intermission. — After about a week, sometimes 
not more than three or four days of apparent convalescence, 
usually between the twelfth and twentieth days of the disease, 



314 LECTURES ON FEVERS. 

the patient is taken suddenly ill with all the phenomena of the 
primary fever, and enters upon the stage of relapse. 

The Stage of Relapse. — The advent of the second attack, 
which usually occurs at noon or in the night, is generally attended 
by chilliness or rigors. The pulse increases in frequency, but 
reaches its maximum more slowly and gradually than in the pri- 
mary paroxysm ; occasionally within twelve hours it reaches 140 
per minute. The temperature rapidly rises to 102° Fahr. — ex- 
ceptionally to 106° Fahr. or 108° Fahr. — on the first day; but 
soon the body-heat is higher than during the invasion attack. 
The common symptoms are usually those of the primary parox- 
ysm, only they are, as a general rule, less marked, and are at- 
tended by greater debility. As in the primary paroxysm, the 
blood-spirillum is always found upon microscopic examination. 

The duration of the relapse varies from two to seven days; 
usually it is about three days. Generally the second crisis, which 
occurs oftenest during the night, is as abrupt as the first, being 
accomplished in a few hours, and accompanied by a profuse per- 
spiration. From this period the patient usually goes on to com- 
plete recovery. When a second relapse takes place, the mean 
duration of this, the second non-febrile interval or intermission, 
is ten days, and that of the relapse is two or three days. As 
many as three or four relapses may occur, but generally conva- 
lescence is assured after the second non-febrile interval. 

Convalescence. — Convalescence, which usually lasts as long as 
all three preceding periods — three to six weeks — is marked by 
a condition of comparative comfort. But, notwithstanding the 
rapid return of the appetite, the emaciation, the loss of strength 
and the arthritic and muscular pains remain for some time. 
Anaemic murmurs, frequently noticed during the course of the 
fever, are often present during the first half of the convalescing 
stage. Post-febrile oedema of the feet and sometimes of the 
hands and face is not infrequent. 

The death-rate in relapsing fever seldom exceeds two or three 
per cent. Death may occur, usually at the close of the relapse, 
from the intensity of the fever, and the consequent exhaustion, 
In a limited number of cases it may take place in consequence of 
lung complications, sudden heart-failure, cerebral hemorrhage, 
pysemia following splenic abscess, or from urinary suppression 
with coma and convulsions. 



COMPLICATIONS. 315 

Complications. — Pneumonia, often double, is a frequent and 
serious complication of relapsing fever. When death occurs 
from this complication, it is usually within a week or ten days 
after the first crisis. 

Cerebral hemorrhage is a frequent and fatal complication, oc- 
curring mostly about the termination of the specific fever. It 
is marked by the rapid onset of cerebral compression, the speed- 
ily deepening coma, and the previous absence of head symptoms. 
Contracted pupils, when present, indicate surface cerebral irri- 
tation. 

Sudden collapse and death from heart-failure may occur as a 
result of organic disease. 

Post-febrile ophthalmia is a not infrequent complication, ap- 
pearing usually a few days after the invasion attack. It occurs 
oftenest in adult males, and affects chiefly the right eye. 

Diarrhea and dysentery often appear as complications. They 
occur most frequently during the relapse, and in some epidemics 
they are so severe and exhausting as to cause death. 

Enlargement of the spleen at times remains persistent; in rare 
instances abscess accompanied by pyaeniic symptoms occurs. 

Ancemia not infrequently occurs as a sequel. 

Duration. — The duration of an abortive attack of relapsing 
fever is fourteen days, of which seven are febrile. That of an 
ordinary attack with one relapse is twenty-six days, of which 
twelve are febrile. Rarer attacks with two relapses have an av- 
erage duration of thirty-nine days, of which fifteen are febrile. 

ANALYSIS OF CHART. 

The Nervous System. — Vertigo occurs as an early symptom, 
and is more or less marked during the first and third stages of 
the fever. 

Headache is the commonest of all symptoms. It is chiefly 
frontal, and the feeling is oftenest described by patients as 
"great heaviness," sometimes as "splitting" or "throbbing." 
Its duration is usually limited to that of the febrile state. In 
the severer forms of the disease, marked at the close by delir- 
ium, the headache is often severe. 

Muscular, arthritic and osseous pains are nearly always pres- 
ent. They commonly appear with the fever, augment and decline 



316 



LECTURES ON FEVERS. 

CHAKT XIII.— Relapsing Fever 



Nature: 


Epidemic. Contagious. 


Etiology : 


The Spirillum Obermeieri. Famine. 


Initial Symptom: 


Chilliness or rigors. 


Stages: 


Prim'ry Paroxysm 


Intermis- 
sion. 


Relapse 


Convalescence. 


Duration: 


Six to seven days. 


Three to 
seven days 


Two to seven days 


Three to six weeks 


Cutaneous 
Surface: 


First dry then 
moist. 


Moist. 


Dry and hot. 


Occasionally 
desquamation. 


Nervous System : 


Vertigo. Insomnia 
Frontal headache. 
Muscular pains. 


SUDDEN SUBSIDENCE OF SYMPTOMS. 
DEBILITY. 


Headache. Mus- 
cular pains. Great 
debility. 


Debility. Muscu- 
lar weakness. 


Temperature: 


Rises rapidly 
lOPorlOS-'lstday. 


Rises rapidly. 
102° to 103°. 


Normal. 


Pulse: 


110° to 160 y 
Fuli and frequent. 


110 to 140, 
Soft. Compress- 
ible. 


Slow. 
Anaemic Mur- 
murs. 


Tongue: 


White or yellowish 
White fur. Moist. 


Furred. 


Clean and moist 


Bowels ; 


Constipated. 


Constipated. 


Normal. 


Stomach : 


Thirst. Nausea. 
Greenish vomit- 
ing Epigastric 
tenderness. 


Vomiting. 
Epigastric tender- 
ness. 


Normal appetite. 


Liver: 


Enlarged. 
Jaundice. 


Enlarged. 

Jaundice. 

• 


Normal. 


Spleen: 


Enlarged. 


Enlarged. 

Abscess. 


Returns to 

Normal. 


Urine: 


Scanty. Dark. 
Lows p. gr 


Normal. 


Scanty. Dark. 
Slightly albumin- 
ous. 


Normal. 


Blood: 


Spirillum present. 


Spirillum 
absent. 


Spirillum present. 


Spirillum absent. 


Defervescence : 


Rapid and critical 
on tith or 7th day. 


Attained. 


Rapid and critical 
on i5th to 25t h day. 


Attained. 


Complications: 


Bronchitis. Pneumonia. Ophthalmia, 
Cerebral hemorrhage. Splenic abscess. 


Prognosis: 


Favorable. Mortality is from 2 to 4 per cent. 


Recurrences: 


A previous attack affords no immunity. 


1 neubation : Five to seven days. 



THE DIGESTIVE TEACT. 317 

with the changes of pyrexia, and subside at the crisis, leaving 
behind them marked muscular weakness. 

Debility comes on early, and is generally marked. It is not as 
severe as in typhus fever, but being commonly associated with 
vertigo and arthritic and muscular pains, it compels patients to 
take to their beds. The ordinary strength is not regained until 
convalescence is far advanced. 

The Digestive Tract. — Thirst is a constant symptom during 
the fever. It is usually most persistent and intense in subjects 
of low type of fever. 

Appetite is usually wanting during the fever. At the critical 
fall it often returns as promptly as the other signs of relief. An 
inordinate appetite has been noticed in some cases, near the end 
of a relapse, just before probable acme and sudden death by 
cerebral hemorrhage. 

The tongue, as a rule, undergoes changes corresponding very 
closely with those taking place upon the cutaneous surface. It 
is dry when the latter is dry, and moist when it is moist. It is 
generally coated, the fur being either whitish, yellowish-white 
or brownish in color. Occasionally the organ is flabby and 
indented at its edges by the teeth. Sometimes, particularly in 
young persons, the papillae are enlarged, and the tongue presents 
a " strawberry '' aspect. Pallor of the tongue usually attends 
the crisis. 

Nausea, either alone or preceding and alternating with vom- 
iting, is a not infrequent symptom. 

Vomiting occurs alike in the abortive and ordinary or relapsing 
forms of the fever. It is generally active in character, and oc- 
curs of tenest in young men. The vomited matters consist of the 
ingesta, and of glairy mucus and diluted bile of varied hue. 
Specks and small streaks of blood are sometimes present in the 
ejected mucus. At times, when the stomach is unusually irrita- 
ble, the change of posture will induce the recurrence of vomiting. 

Epigastric tenderness is a common symptom. Notable ten- 
derness exists, in some cases, over the liver and spleen. 

Splenic enlargement is a prominent and characteristic symp- 
tom. It occurs early and may often be detected during the first 
twenty-four hours. It steadily increases in size during the feb- 
rile period, and rapidly diminishes in the intermission and during 



318 LECTURES ON FEVERS. 

convalescence. At the close of the primary paroxysm it has 
attained its maximum size, which may be two or three times its 
natural bulk. It can then be felt through the abdominal walls. 

The liver is slightly enlarged. 

Jaundice occurs in a small proportion of cases. It rarely ap- 
pears before the third or fourth day of the invasion attack, dis- 
appears during the intermission, and reappears during the 
relapse. It is seldom persistent, usually vanishing in a few days. 

Constipation may be present for a few days before the onset 
of primary fever. Usually the alvine functions remain undis- 
turbed. Intestinal catarrh sometimes occasions more or less 
persistent diarrhea. 

The Temperature. — In well-marked uncomplicated cases the 
course of the fever is typical (fig. 16). The temperature rise 
is always sudden and is usually connected with increasing growth 
and spore production in the blood. Often during the initial 
chill or rigor it reaches 102" Fahr., and generally within twenty- 
four hours it goes np to 104° Fahr. or 106° Fahr. Not infre- 
quently it attains its maximum on the first day. Generally the 
highest temperature is observed just before the crisis. The tem- 
perature curve is irregularly remittent, being interrupted by sol- 
itary peaks of exacerbation. The morning and evening varia- 
tions in the diurnal curve, range from a few tenths to one or 
one and a half degrees. 

At the crisis the downfall occurs with a rapidity that is char- 
acteristic. The temperature falls from 4° Fahr. to 10° Fahr. in 
an unbroken line within twelve hours. For one or two days the 
morning temperature may even be sub-normal — 95° Fahr. to 97° 
Fahr 

With the onset of the relapse, the temperature rise is again 
quite sudden, reaching 102' Fahr. or 104° Fahr. in an abrupt 
line within a few hours. The peaks grow daily higher and 
higher, and the last represents the maximum temperature of the 
relapse, which is somewhat higher than that of the primary par- 
oxysm— 105° Fahr. to 108° Fahr. 

Defervescence usually succeeds by a rapid and unbroken fall 
pf 7° Fahr. or even 12° Fahr. in twelve hours — a fall greater 
than that of any other disease. 

The Pulse. — The pulse rises rapidly, and varies from 90 to 



TEMPERATURE RANGE. 



319 



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320 LECTUKES ON FEVEES. 

120 or 14:0 per minute. It is eight or ten beats faster in the 
evening than in the morning. It is often full and tense during 
the febrile paroxysm, but becomes soft and compressible after 
the crisis. During the rapid defervescence following the crisis it 
may fall from 140 to 50 in a few hours. 

The cardiac impulse and first sound are weakened after the 
crisis, but gradually regain their power as convalescence becomes 
established. During the primary paroxysm and the relapse, soft 
systolic murmurs are not infrequently heard upon auscultation, 
at the base of the heart. 

Tlie Cutaneous Surface. — In both the primary paroxysm and 
the relapse, the skin becomes moist shortly before the tempera- 
ture declines. The critical termination of the relapse is often 
attended with sweat, more copious than in an intermittent par- 
oxysm. In most cases the sweating is so excessive that the 
clothes and even the bedding become saturated. Partial or 
nocturnal sweating is not uncommon for two or three days after 
the crisis. 

Sudamina, varying in size from a pin point to a split pea, are 
observed in some epidemics. They are commonest at the crisis;, 
sometimes they appear in successive crops. A branny exuvium 
or a desquamation of the cuticle in flakes sometimes occurs. 

The Urine. — The urine-changes in relapsing fever are singu- 
larly slight. At or near the acme, the urine is scanty, acid, and 
high-colored. Though clouded, it leaves no lateritious deposit 
on cooling, such as is found in other febrile diseases. 

Albumen in small proportions is not uncommon. Blood and 
tube-casts are rarely observed. When jaundice exists, bile pig- 
ments are present in the urine. 

Morbid Anatomy. — No invariable lesion is found after death 
from relapsing fever. The special features of the disease are 
principally cerebral hemorrhage, pneumonia, collapse of the 
lungs, enlargement and pallor of the liver and kidneys, enlarge- 
ment or firmness and infarcts of the spleen, congestion and ex- 
travasations in the intestinal walls. 

Emaciation is rarely extreme. 

Cadaveric rigidity appears early and is long continued. 

The brain presents no characteristic changes. Serous effu- 
sion, usually clear* and yellowish, and practically limited to the 



MORBID ANATOMY. 321 

loose sub-arachnoid tissue at the vertex and sides of the brain 
ds sometimes observed. Marked effusion is most commonly seen 
■at the close of the febrile paroxysm. More or less copious hem- 
orrhages in the arachnoid and sub-arachnoid spaces, especially 
over the upper convexity of the hemispheres may be found. 
Fatty degeneration of the smaller vessels sometimes attends the 
■cerebral hemorrhage. The deeper seated substance of the brain 
rarely becomes affected. Heydenrich and Carter have noticed 
the possible formation of emboli in the smaller vessels from the 
clustering and aggregation of the spirilla into compact masses. 

The spleen will be found considerably enlarged, especially if 
death has occurred during the febrile state. The capsule is 
thickened, smooth, tense and slightly clouded, and the malpi- 
ghian tufts are more prominent than normal. After the crisis 
the organ will be found to be diminished in size, and the capsule 
will present a shriveled appearance. Wedge-shaped infarc- 
tions, or altered portions of the spleen-pulp, are occasionally 
met with. They are commonest at the edges of the organ. Ex- 
ceptionally they break down and form abscesses. 

The liver is commonly enlarged and of a yellowish-gray hue. 
The enlargement may be due to cloudy swelling and pigmentary 
or fatty transformation of the gland cells. Congestion is of ten- 
• est noted immediately after the cessation of fever. 

The kidneys are enlarged, flabby, friable and of a pale yellow- 
ish color. Congestion- of the mucous membrane of the pelvis, 
and cloudy swelling of the renal cells are frequently seen. 

The stomach frequently displays small spots of blood extrava- 
sation upon its mucous surface. 

The intestines present no changes other than those of conges- 
tion, inflammation or hemorrhage, affecting the ileum and lower 
end of the jejunum. 

The heart, in a large proportion of cases, shows no structural 
change. In some instances fine, granular infiltration of the mus- 
cular fibres has been observed. Blood-clots are generally present 
in the heart-cavity; and small quantities of clear serum are fre- 
quently found in the pericardial sac. 

The lungs frequently display the changes in structure incident 
to the occurrence of bronchitis or pneumonia as complications. 

The blood of relapsing fever patients presents a number of 
striking changes. During the primary paroxysm, for the first 



322 LECTURES ON FEVERS. 

few days the plasma is often clear, later on it becomes clouded. 
The white blood-cells are increased in quantity, and the red discs 
frequently present a bent or cupped, shriveled aspect. Leuco- 
cytes increase in numbers as the attack progresses, until the 
acme is reached. Large, colorless granule-cells are frequently 
observed at the close of the febrile period. They are oftener 
found in the relapse than in the primary paroxysm. Their source 
is supposed to be from the spleen and lymphatic system. Fila- 
ments, granules, or short rods have also been observed. They 
have been noted during the primary paroxysm, but have been 
oftenest seen at the critical defervescence. Their nature and 
origin is unknown. 

Spirilla or spirochseti are commonly present. As seen in 
freshly drawn blood, they appear as colorless, slender, twisted 
filaments, actually moving in the liquid plasma, until coagulation 
begins, when they seek refuge amongst the red corpuscles. The 
quiescent filaments have a length of from two to six times the 
diameter of a red disc. They resemble a spiral rod, with from 
four to ten spiral turns. From five to ten spirilla are generally 
visible in the field of the microscope at one time; occasionally 
they appear in swarms. As a rule, not less than one spirillum 
will be found in an ordinary specimen — -one-fourth of a drop — • 
of infected blood. If there are 250,000 millions of red discs in 
the human body, one spirillum to one thousand discs would give 
an aggregate of about two hundred and fifty millions of blood- 
parasites. 

Spirilla are absent during the early stage of the incubation 
period, but are present during the latter part of \t They rapidly 
increase with the advent and during the progress of the fever. 
They disappear, as a rule, rapidly, with the cessation of the 
fever. The ordinary duration of individual spirillar organisms 
has not been ascertained. The length of visible blood infection 
varies from two or three to eight or ten days. 

By contact with- the sick, or by inoculation of blood containing 
these spiral organisms or their germs, relapsing fever may be 
conveyed to new or old subjects. 

Differential Diagnosis. — The diagnosis of relapsing fever 
after the disease has ended is extremely easy; but at the begin- 
ning of an epidemic, during the primary paroxysm, it is often 
attended with difficulty. 



DIFFERENTIAL DIAGNOSIS. 323 

The distinctive characters are, the abruptness of invasion, the 
unusual rise in temperature, the prominence of severe muscular 
pains of a rheumatic character, the occasional occurrence of 
jaundice accompanied by more or less tenderness and fullness in 
the hypochondrium, the critical defervescence about the fifth or 
seventh day, and the almost constant occurrence of a relapse on 
the twelfth or fourteenth day. 

The pathognomonic test, I would have you remember, is the 
presence of spirilla in the blood during the periods of invasion 
and relapse. Do not understand me as saying that the disease 
is to be invariably recognized by this blood-test, but believe me 
as affirming that the experiments of recent investigators dem- 
onstrate that when the test is applicable it settles for good a 
doubtful diagnosis. 

To demonstrate tfie spirilla it is necessary to employ magnify- 
ing powers of not less than 500 diameters, and for special inves- 
tigation the higher power immersion-lenses are needed. Carter 
recommends that a minute drop of fresh blood be taken from the 
washed finger of the patient, by pricking with a needle, and 
placed on a thin glass cover, which is then inverted and put on 
the slide for examination. The examination is best conducted 
by daylight. In cases of doubt more than one specimen should 
be examined. Dried specimens are not as serviceable as fresh 
ones. 

The diseases with which it is possible to confound relapsing 
fever are, typhoid fever, typhus fever, cerebro-spinal fever, re- 
mittent fever, yellow fever, dengue, small-pox (previous to erup- 
tion) and measles. 

The chief points of contrast between relapsing fever and 
typhus, typhoid (p. 166) and cerebro-spinal (pp. 166 and 236) 
fevers, you are already so familiar with that their repetition is 
unnecessary. 

Remittent f evei', especially when tropical or sub-tropical, occa- 
sionally closely resembles relapsing fever. It differs, however, 
by being of malarial origin, and by showing pigment granules 
and the bacillus malarise (p. 55) instead of the blood-spirillum. 
Yellow fever sometimes closely resembles i elapsing fever. 
The latter, however, is always propagated by contagion, while 
the former is not. An enlarged spleen is the rule in relapsing 



324 LECTURES ON FEVERS. 

fever, and the exception in yellow fever. In all cases an examina- 
tion of the blood will prevent error. 

Dengue may be distinguished by the eruption and by the 
character of the remissions. 

Small-pox presents some points of resemblance to relapsing 
fever during the period of invasion. After the third day, the 
diagnosis is rendered positive by the decline of the fever, and 
the appearance of red spots along the edges of the hair. 

Measles is to be diagnosticated from relapsing fever by the 
eruption, by the course of the fever, and by the catarrhal symp- 
toms of the premonitory stage. 

Prognosis.— The prognosis in relapsing fever is favorable, the 
death-rate being about three per cent. The greatest risk of life 
attends the primary paroxysm and the first relapse. Absence of 
crisis after the seventh day of the primary paroxysm should 
excite apprehension. If, after the crisis, the liver and spleen 
continue enlarged and tender, there is risk of pneumonia or dys- 
entery. Shortening and interruption of the post-critical defer- 
vescence indicates risk from complications. 

Usually death occurs, not from the disease, but from some 
complication. The greatest danger is from sudden syncope. A 
fatal termination may occur from pneumonia, uraemia, dysentery 
or cerebral hemorrhage. 

One attack confers no immunity from reinfection. 

Treatment. — Prophylaxis, — As over-crowding, poverty and 
famine are strong predisposing causes of relapsing fever, the 
poor of an infected district, should, upon the outbreak of an 
epidemic, be provided with sufficient wholesome food, and more 
spacious apartments. Valid sanitary preventive measures should 
be early applied. All defective drainage should be remedied, all 
filth and garbage should be removed. All waters used for drink- 
ing purposes must be boiled before used. Adequate home and 
personal hygiene should be observed. Infected houses should 
be evacuated and thoroughly disinfected and cleansed. A camp 
of refuge should be established for the poverty-stricken patients. 
Abundant ventilation, and especially room-space for each pa- 
tient, is of the first importance. In all large cities and in local- 
ities where relapsing fever frequently occurs, a permanent fever 
hospital is a sanitary necessity. 



PRINCIPAL REMEDIES. 325 

Absolute cleanliness in the sick room must be insisted upon. 
All soiled clothes should be thrown into a five per cent solution 
of carbolic acid, or some other disinfectant, and then imme- 
diately washed in boiling water. Piatt's chlorides should be 
sprinkled upon the bed and about the room. After convalescence 
the patient's apartment should be fumigated by burning sulphur, 
and then thoroughly aired, the woodwork cleansed with carbol- 
ized water, and the walls whitewashed. The infected bedding 
should be disinfected by prolonged exposure to heat or to sulphur 
fumes, and then shaken or beaten and exposed to the wind and 
sunshine for several days. 

Principal Remedies. — Baptisia is oftenest indicated in the 
early days of the invasion attack, and when gastric symptoms 
predominate. It is reported as having lessened the severity of 
the disease, and hastened the crisis. Bryonia is the best remedy 
during the latter days of the primary paroxysm, and in the re- 
lapse. Arsenicum stands next to bryonia, and is indicated dur- 
ing the fever when watery diarrhea and vomiting are present. 
Eupatorium perf. will be of service when the rheumatoid pains 
are very severe, and when there is great tenderness in the epi- 
gastrium and right hypochondrium. Nux vom. is usually indi- 
cated during the intermission. Helonin or mere, cor, may be 
given as an intercurrent remedy for albuminuria; and cantharis 
or apis for difficult urination with scanty discharge. Urinary 
retention calls for either opiu m or hyos. Phosphorus ov phos- 
phoric acid will be frequently needed during convalescence, 
Berber is vulg. will prove serviceable when there is considerable 
enlargement of the spleen; and mere, bi-jocl when both the liver 
and spleen are enlarged. 

Leading Indications. — Aconite. — In the first paroxysm when 
there is high fever, great restlessness and anxiety, full, hard, 
quick pulse, and pain in the forehead and temples. Great thirst 
for small quantities of cold water prevails during the paroxysm 
(ars., opp. bry.). In sanguine and plethoric individuals, 

Apis mel. — Great desire to sleep. Soreness of the limbs and 
joints. Great soreness in the pit of the stomach when touched 
(bry.). Soreness in the region of the spleen. Urine scanty and 
high-colored. Suppression of urine (hyos., opium). Oppres- 



326 LECTXJKES ON FEVERS. 

sion of the chest with a sensation of smothering during the par- 
oxysm , 

Arnica. — Great weariness compelling the patient to lie clown, 
yet the bed feels too hard (bapt). Confused feeling in the head 
with pressure over the right brow. Great heat in the head with 
coldness of the body; cold sensation at a small spot on the fore- 
head. Heat intolerable during the fever, but the slightest motion 
of the bedclothes causes chilliness (mix). Petechias 

Arsenicum. — Great restlessness and anxiety, Death-like 
color of the face (carbo. veg.). Pain and distension in the left 
hypochondrium. Aversion to food. Tongue furred at the edges, 
with red streak in the center, and red tip. Thirst for cold water, 
wants little at a time but often (aco., cinch., opp. bry,). Burning 
in the stomach with vomiting and diarrhea. Small, weak, com- 
pressible pulse. Great weakness and prostration after the par- 
oxysm (verat. alb.). (Edema of the extremities. 

Baptisia. — Great nervous restlessness, especially at night. 
Dull, stupefying headache (gels.). Head feels as if scattered 
about; tries to get the pieces together. Dark, red face with be- 
sotted expression. Tongue coated, brown and dry, particularly 
in the center. White furred tongue with red edges. Tired, 
bruised, sick feeling all over the body. Feeling as if the lower 
limbs were separated from the body (opium). Patient changes 
position frequently because the bed becomes too hard (arnica). 
Offensive secretions. 

Bryonia. — Desire to lie down during the fever; setting up 
causes nausea and vomiting; vomiting first of bile, then of fluids. 
"Violent throbbing headache, as if the head would burst. "Vertigo 
with sensation as of the head turning in a circle (bell.). White 
or yellow coating on the tongue. Excessive thirst, drinks large 
quantities at a time, and at long intervals. Stitches in the liver 
and spleen (mere). Sweat on single parts only, or on side on 
which the patient lies. Neuralgic and rheumatic pains, worse on 
motion. Fullness and oppression in the pit of the stomach and 
bowels. Epigastric region painful to touch and pressure. 

Camphor. — Sudden and great sinking of strength (ars.). 
Cold sweat all over the body (verat alb.). Sudden sinking 
spells. Small, weak, scarcely perceptible pulse (carbo. veg.)* 



LEADING INDICATIONS, 327 

Great thirst; coldness of the tongue (carbo. veg., verai. alb.). 
Extreme sensibility to cold air (nux). 

Chamomilla. — In children and in nervous adults. Gastric 
symptoms (bapt.). Excessive sensitiveness to pain (coffea). 
Yellow coated tongue. Tongue white at the sides and red in the 
middle (opp. tart, emet ). Frequent emissions of large quantities 
of pale urine (helonin). 

Cimicifuga. — Neuralgia in the forehead and eyeballs. Sink- 
ing sensation at the stomach with nausea and vomiting. Ner- 
vous weakness and prostration. Excessive muscular soreness. 
Obstinate sleeplessness. Threatened abortion. 

Cinchona. — Sense of internal illness as of impending disease. 
Pressure in the head from within outwards as if it would burst, 
lelieved by -hard pressure. Great lassitude and exhausting 
sweats during the intermission. Saffron yellow color of the skin; 
the patient looks jaundiced. Enlargement of the liver and 
spleen. Anaemic and cachectic appearance. 

Eupatoriiim perf. — Headache with sore feeling internally. 
Nausea with retching and vomiting of bile. Bone pains in every 
stage. Pain in the back and limbs as if bruised (am. ). Thickly 
coated tongue with thirst and vomiting after drinking. Sallow- 
ness of the skin; morning diarrhea (podo.). Perspiration in- 
creases the headache, but relieves all the other pains (nat. mur.). 
Soreness of the region of the liver on pressure (mere). Great 
tenderness of the epigastrium. Loose cough during the inter- 
mission. 

(jelsemium. — Dullness of the mental faculties (bapt. ). Great 
languor and drowsiness. Bruised pains in the muscles, general 
rheumatic symptoms (dm.). The tongue is coated wdiitish or 
yellowish and there is a sticky feeling in the mouth. Intense 
burning fever accompanied by a sensation of falling. Sweat is 
apt to be profuse and relieves the pain (nat. mar., opp. ferrum). 
In children and nervous young people. 

Leptandra. — Dull aching pain in the liver (mere. ). Burning 
distress in the epigastric and hypochondriac regions. Constant 
nausea with vomiting of bile. Jaundice with clay-colored stools. 
Thin, black, fetid, watery evacuations with severe pains after 
stool. Chronic diarrhea and dysentery. Brownish urine. 



328 LECTURES ON FEVERS. 

Mer cur iu$. — Great anxiety and restlessness. Heaviness in- 
the head with great inclination to sleep. Swollen, soft, flabby 
tongue, taking the imprints of the teeth. Dirty-yellow coating 
on the tongue. Eegion of the liver painful and sensitive to con- 
tact (bry., eupat. perf.). Icteroid hue of the skin. Tearing 
pains in the joints, worse at night and in the warmth of the bed. 
Bilious, slimy or watery diarrhea. Sudamina. 

Nux YOm. — Gastric or bilious symptoms predominate. Hun- 
ger with great aversion to food. Flatulent distention of the 
abdomen after eating (cinch., lycop.). Alternate constipation 
and diarrhea (bry. ). Throbbing in the region of the liver (bry. ). 
Profuse sweat after the severest paroxysms. Chilliness on mov- 
ing the bedclothes. Has been recommended as a preventive. 

Phosphorus. — Pale, sallow, or changeable color of the face. 
Inability to concentrate thought (am., rhus). Thirst with de- 
sire for very cold drinks (rhus). Region of the stomach painful 
to the touch. Feeling of coldness in the abdomen (ars.). Hard, 
dry cough with oppression in the chest. Loud mucous rales in 
the lower lobes (ipecac, tart emet). Hepatization of the lungs- 
Rose spots and ecchymoses. Profuse epistaxis. 

Phosphoric acid. — Pale, sickly complexion. Hemorrhage 
from the nose of dark blood (ham.). Grayish coating on the 
tongue. Headache, worse from the least shaking or noise (bell. ). 
Feeling of heaviness in the region of the liver (podo.). Fre- 
quent, small, feeble pulse. Profuse night (mere, tarax.) and 
morning ( cinch. ) sweats. Pressure in the stomach after eating. 
Thin, whitish-gray evacuations. In young persons who have 
grown very rapidly. 

Rhus tox. — Fullness and heaviness in the forehead, worse 
from opening or moving the eyes (p>uls.). Dark, livid redness 
of the cheeks. Dry, red, cracked tongue (bapt.). Redness of 
the tip of the tongue in the shape of a triangle. Great thirst 
for cold drinks (phos.), especially cold milk. Dry, tickling 
cough worse in the evening and before midnight. Profuse sour 
morning sweats. Erysipelas with great burning. 

Samhucus. — Intense heat with great dread of uncovering. 
Excessively abundant sweat. The perspiration continues through 
the intermission. (Edematous swelling of the feet, instep and 
lower part of the legs. 



HYGIENIC AND DIETETIC TREATMENT. 329 

Terebintliina. — Headache with intense pressure and fullness 
of the head. Tongue red, smooth and glossy. Vomiting of mu- 
cus, blood or bile. Small, weak, thready pulse. Cold, clammy 
sweat all over the body (vercd. alb.). Burning, drawing pains 
in the kidneys with bloody urine. Strangury. Great prostration. 

Veratrum alb. — Sudden sinking of strength. Hippocratic 
countenance. Cold perspiration, especially on the forehead. 
Tongue cold (carbo. veg. ) or coated white with red tip and edges. 
Violent thirst for cold water (ars., jplios.). Spasmodic constric- 
tion of the throat. Suppression of urine (apis). Nausea and 
vomiting with frequent serous, watery or bloody stools (momor- 
dica). Petechias on the extremities. 

HYGIENIC AND DIETETIC TREATMENT. 

Relapsing fever patients should be kept quiet in bed during 
the primary paroxysm, and free ventilation secured. The bed 
and room should be sprinkled with Piatt's chlorides, or some 
other disinfectant. The bed and body linen should be changed 
daily and thrown into a vessel containing a solution of carbolic 
acid before being removed from the room, and afterwards washed 
in boiling water. All unnecessary visiting should be prohibited, 
and, as a rule, the sick should not be allowed to leave their rooms 
until the period of relapse shall have passed. 

A carefully regulated and nourishing diet is of the utmost im- 
portance, because deficient alimentation has in the majority of 
cases been a predisposing cause. From one to two quarts of 
milk should be administered daily during the paroxysm. Meat 
broths and light farinaceous food, ice cold koumyss, weak iced tea 
with lemon-juice, and other cooling drinks may be allowed. 
Buttermilk is often exceedingly grateful to patients and is highly 
beneficial. 

When the temperature begins to decline and sweats appear, 
the body should be kept dry, and warm nourishing drinks and 
warm applications resorted to. 

During the intermission as much substantial food as can be 
digested should be allowed. 

Any tendency to heart-failure at the time of the crisis, or early 
in convalescence, should be obviated by the early use of wine, 
champagne or spirits. The pulse and the character of the first 



330 LECTURES ON FEVERS. 

sound of the heart are the best guides as to the amount of stim- 
ulation necessary. 

Excessive tenderness of the spleen and liver may be relieved 
by the use of fomentations and poultices. The tumefied spleen 
may be decidedly reduced in volume by means of the induced 
electric current. With partial suppression of urine at the crisis, 
flaxseed poultices to the loins are beneficial. 

As the patient enters upon convalescence after this blood-in- 
fection, pure air and good diet, mental and bodily rest, are 
especially desirable. 



LECTURE XXI. 

Small -Pox. 

I shall this morning commence the history of the contagious 
fevers that are specially characterized by an eruption, and hence 
have been termed eruptive fevers. They are five in number, 
small-pox or variola, including varioloid, varicella or chicken- 
pox, scarlet fever or scarlatina, measles or rubeola, and german 
measles or rotheln. 

They are all propagated by a distinct morbific agent, repro- 
duced within the body, and are characterized by a definite period 
of incubation. They run a clearly defined course, and are at- 
tended by active febrile symptoms, and by an eruption which 
passes through a regular series of changes and then disappears. 
They are all contagious, and, as a rule, attack the same person 
but once. 

The most remarkable of all the eruptive fevers, and the first 
of which I shall speak, is small-pox. 

Definition. — It may be defined as an acute, highly contagious 
fever, of from two to four weeks duration, characterized by a 
pustular inflammation of both the cutaneous and mucous sur- 
faces, accompanied by symptoms of considerable constitutional 
disturbance. It consists of: 1. An initial stage, ushered in by 
a chill, and marked by anorexia, nausea, vomiting, headache, 
pain in the small of the back, sore throat, active fever, rapid 
pulse, and occasionally an initial erythematous rash. 2. A stage 
of eruptions introduced on the third day of the disease by a red- 
dish, millet-seed or pin-head sized eruption, and marked by sud- 
den subsidence of febrile symptoms — the eruption as it develops 

(331) 



332 LECTURES ON FEVERS. 

becoming dark-red and papular on the fourth day, slightly 
vesicular on the sixth day, completely vesicular, pea-sized and 
frequently umbilicated on the seventh or eighth day. 3. A stage 
of suppuration on the eighth or ninth day of the disease, when 
the pustules are fully formed, secondary fever comes on, the 
temperature rises as high or even higher than during the initial 
stage, augmentation of all the symptoms occurs, the face swells, 
general itching becomes intolerable, and the patient emits a 
sickly odor. 4. A stage of desiccation about the eleventh or 
twelfth day of the disease, when the pustules burst and crusts 
or scabs form, the temperature falls, and the appetite returns — 
the crusts eventually falling, leaving pigmented cicatrices and 
occasionally pits. After death, constant lesions of the cutaneous 
surface, lungs, brain, liver, spleen and kidneys are found. 

Synonym. — Its common synonym and first name is variola. 
The term variola, the diminutive of varus, a pimple, is of 
monkish origin, but was first applied to this disease by Constan- 
tinus Af ricanus. The term pock is of Saxon origin, and signifies 
a bag or sac. The epithet small, was added to it soon after the 
introduction of the great pox (syphilis) into Scotland from 
America in 1498. 

History. — Although small-pox had certainly been known for 
several centuries before it was described, the earliest clear ac- 
count of it was given by Gregory, of Tours, in the year 581. 
Rhazes, an Arabian physician who practiced in Bagdad, gave the^ 
first full and scientific description of the disease in 910. 

The success of the Saracen arms in Spain and Sicily in the 
eighth century assisted the spread of small-pox throughout Eu- 
rope. Traveling westward it reached England about the close 
of the ninth century. 

It raged throughout Europe about the time of the crusades, 
and visited England again in 1241. Pest-houses were first gen- 
erally erected at this time for the purpose of checking the dis- 
ease and of affording assistance to sufferers. 

At the close of the fifteenth century it started in the Nether- 
lands and extended to Germany and Sweden. 

It was introduced into Mexico — its first appearance on this 
continent — in 1520, by a negro slave. This epidemic, as is the 
rale, when diseases first appear in any country, was unusually 



HISTORY. 333 

severe, and proved alarmingly fatal. According to Spanish his- 
torians, in Mexico alone, three and one-half millions of people 
fell victims to the scourge. In Hayti it carried off all the inhab- 
itants, and in Brazil whole tribes were completely destroyed. 

In the seventeenth and eighteenth centuries it prevailed in 
England and in Europe, and was the greatest scourge of the age. 
As a proverb of the times expressed it, " from small-pox and 
love, but few remain free." Small-pox was first definitely sep- 
arated from measles by Sydenham in 1633. 

In 1649, small-pox first occurred in Boston, and afterward re- 
appeared every decade during the century. 

In 1721, one-half of the population of Boston was attacked 
with the disease, and one-thirteenth of those attacked, died. 

In 1767, a terribly fatal epidemic raged in Greenland, Siberia 
and Kamtchatka. 

During the sixteen years following 1783, it is stated that one- 
tenth of the total mortality at Berlin, was due to small-pox. 

An epidemic most remarkable for its extensive diffusion, began 
in Sweden, in 1824 — reached England in 1825, spread to France 
in 1826-27, and ceased in Italy in 1828-29. 

Several epidemics occurred at Copenhagen from 1825 to 1835. 

In 1838, one hundred and fifty thousand Mandan Indians, a 
branch of the Sioux located on the Missouri river, died of the 
disease, leaving only twenty-seven of the tribe, now located at 
Et. Clarke. Catlin asserts, that of twelve millions of American 
Indians, six millions have been destroyed by small-pox. 

In the island of Bombay during the five years following 1848, 
the small-pox deaths among the unprotected were about six per 
cent of the mortality from all causes, and among the protected 
(vaccinated) one per cent. 

In 1870-71, a terrible epidemic ravaged Europe, and in 1871- 
72 the disease prevailed to a considerable extent in Philadelphia. 

In the winter of 1881-82 it prevailed in New York, Chicago 
and Quebec, and in several other large cities of this country 
and Canada. 

Few countries have remained exempt from small-pox. At va- 
rious periods new and destructive epidemics have broken out in 
all parts of the world. The spread of the disease depends 
greatly upon the manner in which the eminently protective rem. 
■ecly, vaccination, is employed. For, to-day, amongst the unpro- 



334 LECTURES ON EEVERS. 

tected (non-vaccinated), small-pox is as destructive and virulent 
as in the past. 

Etiology. — The causes of small-pox are, predisposing and ex- 
citing. 

1. The Predisposing Causes. — Climate has no direct influence 
in producing this disease. 

The season of the year exerts very little influence. Epidem- 
ics arise and pursue their course irrespective of seasons. The 
disease is usually more fatal in summer than in winter. 

Age exerts some influence as a predisposing cause. The ex- 
tremes of life are those on which small-pox falls the heaviest. 
Immunity is reached at no period, and even uterine life does not 
exclude the danger of infection. The susceptibility is greatest 
in children from the seventh to the fourteenth year. 

Sex, in itself, has no influence. 

Occupation, except as it involves actual exposure, does not 
predispose to small-pox. 

Race and nationality exert some influence. The negro and 
Indian races appear to be particularly susceptible. As a rule,, 
they suffer more violently than the white races, even under the 
same conditions. 

Pregnant women are apt to abort or miscarry during the course 
of small-pox. The foetus usually perishes, occasionally it sur- 
vives. 

Lying-in toomen are predisposed to the confluent form of the 
disease, which frequently terminates fatally. 

A previous attack, as a rule, extinguishes the susceptibility to 
the disease. Cases of secondary or recurrent small-pox, how- 
ever, have been described in all ages from Khazes down to the 
present time. 

Non-vaccination exerts a powerful influence. A system un- 
protected by successful vaccination is strongly predisposed to 
small-pox. 

2. The Exciting Cause. — Small-pox is pre-eminently conta- 
gious, and is due to a specific poison, communicable from the 
sick to the healthy by actual contact (upon mucous or abraded 
surfaces) through the atmosphere, by fomites, and by drinking 
water. The exact nature of this poison remains as yet unknown, 
although many writers assert its parasitic origin. It is developed 
and reproduced in the body of a small-pox patient, first takes 



ETIOLOGY. 335 

effect upon the patient himself and is present in the blood and 
in the contents of the pnstule. 

The disease is constantly communicable from the sick to the 
well by actual contact of the virus taken from a small-pox pus- 
tule, with the mucous membrane or with an abrasion of the cu- 
taneous surface. It is also communicable from one individual 
to another by means of the expired air, and the cutaneous exha- 
lations. The distance to which it may be thus conveyed, in the 
open air, is about two and one-half feet. In a small and imper- 
fectly aired apartment the atmosphere may become so impreg- 
nated with the infecting principle that a predisposed person will 
become infected upon a single entrance into the apartment. In 
large and spacious rooms and in the open air, the danger of con- 
tagion is greatly decreased. 

The breath of a small-pox patient frequently conveys, and his 
body emits, especially after the inauguration of the suppurative 
stage, a characteristic, sickly odor. It has been thought that a 
patient in whom this odor is strongly marked, is most likely to 
communicate the disease. 

Besides impregnating his immediate atmosphere, the patient 
imparts the contagion to all articles with which he comes in con- 
tact. In this way not only the clothing and bedding of the 
patient, and the clothes of his attendants, but also the apartment 
in which he has lain may act as fomites. Wooly substances are 
especially apt to absorb and retain the contagion, which under 
favorable circumstances may retain its virulence a year or longer. 
Exposure to the atmospheric air sooner or later destroys it. 

The period at which a small-pox patient is most likely to 
spread the infection is the period of suppuration. Infection 
may, however, take place during any stage, even during the 
period of incubation. 

Small-pox may be contracted by susceptible persons through 
contact with bodies of persons who have died of it. There is no 
evidence that it can be conveyed by the discharges from the 
bowels. 

The period of incubation varies from ten to thirteen days. 

Varieties. — The common and well-recognized varieties of 
small-pox are: 1. Distinct or moderate small-pox, in which the 
pustules remain separate from each other during the whole 
course of the disease; rarely fatal. 2. Confluent small-pox in 



336 LECTURES ON FEVERS. 

which the pustules run together on the face or all over the body; 
dangerous to life. 3. Hemorrhagic small-pox in which there is 
a, bruised appearance from extensive capillary hemorrhages; 
usually fatal on the third day. 

Clinical History. — The clinical history embraces a descrip- 
tion of the period of incubation, the initial stage, the stage of 
eruptions, the stage of suppuration and the stage of desiccation. 

The period of incubation, or the time elapsing between the 
reception of the poison and the onset of the disease, varies from 
ten to thirteen days. If the poison is introduced into the sys- 
tem through inoculation, the duration of this period is shortened 
to two days. 

Stage of Initial Fever. — Upon the termination of the period 
of incubation— usually twelve days after the exposure — the at- 
tack is ushered in by a feeling of chilliness which frequently 
increases to a distinct chill, with severe and characteristic pains 
in the loins, accompanied with frontal headache, and soon fol- 
lowed by high febrile excitement. The pulse is commonly full 
and frequent, rising to 100 or 120, or even to 140 per minute; in 
children it may reach 160. The temperature rises rapidly, and 
may reach 104° Fahr. on the first day, 105° Fahr. on the second 
day, and 106° Fahr. or 107° Fahr. or even higher on the third 
day. The patient is languid and weak in proportion to the se- 
verity of the fever. Not infrequently within twenty-four hours 
after the ushering-in chill, the infected individual, strong and 
vigorous in health, will be unable to get out of bed. 

The skin feels hot and dry, or else is covered with a moderate 
perspiration. The face is flushed, the conjunctivae are injected, 
and there is throbbing of the carotids. The tongue is red at the 
tip and edges, and there is nausea and vomiting with epigastric 
pain and obstinate constipation. There is soreness of the throat 
with pain in the pharynx and more or less difficulty in swallow- 
ing. The respirations are short, frequent and labored. Towards 
evening, on the second or third day, there may be delirium; in 
children delirium and convulsions may occur at the onset of the 
attack. 

Swelling and diffuse redness of the tonsils and soft palate are 
usually apparent at the close of the second day, and occasionally 
minute reddish papules may be recognized upon these parts. At 
times, especially in children, and in women during menstruation 



CLINICAL HISTORY. 



337 



•and confinement, a bright or dull crimson, erythematous rash 
appears, oftenest about the groins, hypogastriuin and inner sur- 
face of the thighs. Less frequently it is observed about the 
axillae, the exterior surfaces of the joints, and the lumbar and 
clavicular regions. It appears mostly about the second day, and 
lasts about twenty-four hours, fading almost completely as the 
characteristic variolous eruption appears. 

Stage of Eruptions. — On the third day of the disease — some- 
times earlier in severe and confluent cases — an eruption appears 
upon the face, especially along the edges of the hair, in the form 
of small, red, elevated papules, resembling measles. These little 
points which rapidly increase in numbers, soon cover the fore- 
head, nose and upper lip, and extending within twelve hours to 
the neck, arms, trunk and lower extremities, cover the entire body. 
Their site is usually around a hair-follicle or the orifice of seba- 
ceous or sweat glands. They are frequently arranged in three's 
and five's in a crescentic shape, two crescents often coming to- 
gether to form a circle. They are at first millet-seed or pin-head 
sized, and are of a pale red color, resembling flea-bites. Soon 
they become conical and hard, and feel almost like shot under- 
neath the skin. They gradually increase in size, and on the third 
day of the eruption a minute vesicular point is formed at their 
apex. This conversion of papules into vesicles occurs first on the 
face, and then on the neck, trunk and extremities. Within the 
next two days the vesicles enlarge to the size of a small pea, and 
become indented or umbilicated. They are nearly hemispher- 
ical, and are surrounded by small, inflamed areolae. Their con- 
tents, which are at first transparent, become whitish and milky. 
The umbilication of the vesicle is characteristic, although all 
vesicles are not umbilicated. On or about the second day of the 
eruption the red elevations which appear on the buccal mucous 
membrane simultaneously with or previous to the eruption on 
the skin, assume the appearance of small, whitish, circular um- 
bilicated points. 

As the eruption appears, the febrile symptoms subside, the 
pains in the head and back vanish, the temperature falls two or 
three degrees, and the pulse is diminished in frequency. 

Stage of Suppuration. — On or about the sixth day of the erup- 
tion, and the ninth day of the disease, the vesicles gradually 
iDecome turbid from the admixture of pus corpuscles. Within 



338 LECTURES ON FEVEES. 

the next two days the pustules become fully formed, maturing: 
first on the face and upper part of the body, and lastly on the 
extremities. With the process of suppuration, a new fever to 
which the term secondary or suppurative fever is applied, makes 
its appearance either alone or preceded by a distinct chill, and 
lasts between four and six days. The temperature rapidly rises 
to 103° Fahr. or 104° Fahr.; and sometimes to 108° Fahr. or 
109° Fahr. at the height of suppuration. The pulse becomes 
bard and full, and fluctuates between 100 and 140 beats per min- 
ute. The headache returns, and passive delirium not infrequently 
occurs. The face and eyelids swell, so that the features are no 
longer to be recognized. The skin becomes tense, hot and dry, 
and emits a characteristic foetid, sickly odor. In the vicinity of 
the pustules it becomes red, tumefied and painful; each pustule 
being surrounded by a hard, broad, red areola. The itching 
now becomes intense. The swelling and soreness of the throat 
increases, and swallowing becomes painful and often impossible. 
Salivation is frequently a prominent symptom. About the 
eighth or ninth day the pustule attains its full size, and the stage 
of suppuration is complete. 

Stage of Desiccation. — The retrogade changes in the pustules, 
begin on the face, and extend in from two to four days to the 
extremities. These changes are marked in some of the pustules 
by the formation of a brown spot in the center, which gradually 
extends and converts the pustule into a hard crust. In others 
the changes are announced by the rupture of the pustules, the 
consequent discharge of their contents, and the formation of 
yellow scabs. Some pustules do not form scabs, but shrink away 
in consequence of the absorption of their fluid contents. 

As desiccation commences the areolae around the bases of tha 
pustules become less inflamed, and the puffiness of the face dis- 
appears. The secondary fever subsides, the temperature of 
the integuments decreases, and the pulse diminishes in fre- 
quency. The urine, which has been scanty, high-colored and 
perhaps albuminous, now becomes normal. 

The drying of the pustules is usually completed in from four 
to seven days. 

The scabs fall off between the eleventh and sixteenth days. In 
some instances they leave blotches of a reddish-brown color, 
which remain visible for five or six weeks, and then disappear 



CONFLUENT SMALL-POX. 339 

leaving no cicatrices. In other cases, usually severe, in conse- 
quence of ulceration and destruction of the cutis, little, dead- 
white, cicatricial "pits " or depressions are formed, which remain 
during life, and give to the face a "pock-marked" appearance. 

During convalescence small abscesses frequently form on the 
thighs and legs. 

The desquamation or falling of the crusts ends somewhere 
between the nineteenth and twenty-fifth, and even the fortieth 
days of the eruption. 

We will now pass on to the consideration of the confluent va- 
riety of the disease. 

Confluent Smali-pox, — This variety of small-pox is much 
more severe than the one we have just been considering. The 
stage of initial fever is frequently shortened to forty-eight hours. 
The temperature often reaches 106° Fahr. and in severe types 
may rise to 110° Fahr. The skin appears inflamed and becomes 
swollen and of darkish hue. On the second day numerous red 
papules seated on a red and swollen skin appear and cover all 
parts of the body. The eruption is frequently dark and livid, 
and petechia are not uncommon. The vesicles as they form in- 
crease the violence of the cutaneous inflammation and are so 
crowded on the surface that their edges run together. The pus- 
tules rapidly follow the vesicles, and tend to coalesce into large 
flat blebs. 

After the appearance of the eruption the temperature falls 
slowly to 103° Fahr. or 104° Fahr. With suppuration it again 
rises as high, and in some cases even higher than during the 
initial stage. 

The secondary fever is much more dangerous than in the dis- 
tinct or moderate variety, and rapidly assumes a typhoid char- 
acter. 

The eruption extends to the mucous lining of the respiratory 
tract in severe cases. The tongue becomes swollen and there is 
great difficulty in swallowing. Pharyngo-laryngitis not infre- 
quently occurs. Violent and persistent vomiting and obstinate 
diarrhea often appear with the initial fever and continue through- 
out the disease. Hemorrhage may take place from the mucous 
surfaces of the alimentary canal and urinary tract. Violent de- 
lirium is of common occurrence, and not infrequently passes 
quite suddenly into a state of coma. In the majority of cases 



340 LECTUKES ON FEVEES. 

albumen appears temporarily in the urine. Bronchitis, pneumo- 
nia, pericarditis, pleuritis and acute fatty degeneration of the 
kidneys, are frequent complications. 

In the stage of desiccation large concentric crusts are formed 
over the confluent patches, while suppuration of the papillary 
layer is going on beneath. After the crusts have fallen, as the 
cutis is more or less extensively destroyed, ugly pits remain, 
often producing permanent and unsightly disfigurements. Per- 
manent loss of hair not infrequently occurs. 

A much more formidable but fortunately rarer variety than 
either of the preceding varieties of small-pox, is the malignant 
or hemorrhagic. 

Hemorrhagic Small-Pox. — Hemorrhagic or black small-pox 
is extremely rare, although cases occur in every epidemic. The 
ushering-in symptoms are occasionally but little different from 
those of the preceding varieties, although the lumbar pain is apt 
to be severe. Frequently the initial fever is extremely violent, 
while during the rest of the time the temperature may not ex- 
ceed 102° Fahr. The pulse is exceedingly frequent and feeble 
from the start, and ranges from 140 to 160 beats per minute. 

The characteristic papules may be preceded by a petechial or 
roseolous rash, and early in the disease the eruption assumes a 
dark color. In the majority of cases the hemorrhagic changes 
begin in the papules situated upon the lower extremities. The 
vesicles as they form instead of filling with lymph, contain only 
a thin, sanguinolent fluid. They are irregular in shape, and 
flabby. They mature imperfectly or not at all, and seldom reach 
the suppurative stage. Petechia and ecchyraoses form between 
the eruptive points. As the vesicles or pocks break or are rup- 
tured, dark scabs are formed. 

The cutaneous surface frequently presents a dark, purplish 
hue, from extensive capillary hemorrhages. The face is swollen, 
the eyelids are thick and ©edematous, the conjunctivae are blood- 
colored, the skin is ecchymotic and the entire features are oblit- 
erated. The tongue is thickly covered with a white fur, and 
white pustules may be seen on the fauces and palate. Hemor- 
rhage from the mucous surfaces not infrequently occurs. The 
mind is sometimes clear, delirium is common, and typhoid stu- 
por may exist. 



ANALYSIS OF CHART. 311 

Death generally occurs on the third or fourth day; occasion- 
ally it happens before the appearance of the rash. It may take 
place from shock, coma, hemorrhagic infarctions of the lungs, or 
rapid exhaustion. 

Complications. — The most important complications of small- 
pox are, inflammations of the serous membranes, subcutaneous 
abscesses, conjunctivitis, otitis, bronchitis, pneumonia, acute 
fatty degeneration of the kidneys, lesions of the intestinal canal, 
articular inflammations and different hemorrhages. 

Duration. — The length of time that elapses between the be- 
ginning of the initial fever and the termination of desquamation, 
varies from three to four or even six weeks. 

ANALYSIS OF CHART. 

The Nervous System. — Chilliness increasing to a distinct 

chill is in the majority of cases the ushering-in symptom of 
small-pox. 

Headache is one of the earlier and more constant attendants. 
It is commonly confined to the frontal region, but may extend 
over the entire head. 

Vertigo is often associated with the headache. 

Delirium is an occasional symptom. It is apt to occur in 
severe cases, and is generally passive in character. Occasionally 
it is active or maniacal. 

Coma, occurs in certain proportion of fatal cases. 

Pains in the back and extremities are prominent diagnostic 
symptoms. They are apt to be intense in proportion to the se- 
verity of the attack. 

Convulsions frequently attend the development of the disease 
in children. 

The Special Senses. — The Eyes. — Conjunctival injection is 
generally present. In the hemorrhagic variety the conjunctiva 
is blood-colored and cedematous. Pustules sometimes form 
upon the conjunctiva of the lids, and more rarely upon that of 
the globe or upon the mucous membrane of the lachrymal tract. 
Keratitis, and, in severe cases, deep ulceration of the cornea are 
not infrequently observed. Eetinal hemorrhages occasionally 
occur in hemorrhagic cases. 

Impairment of hearing, and even complete deafness, not un- 



342 



LECTUEES ON FEVERS. 

CHAET XIV.— Small-Pox, 



Nature: 


Highly contagious. Portable. 


Incubation : 


Ten to thirteen days. 


Stages : 


Initial Fever. 


Eruptions. 


Suppuration. 


Desiccation. 


Duration: 


Three days. 


Five to six days. 


3 to 5 days. 


10 days to 2 weeks 


Eruption : 


Roseola vario- 
losa, occasion- 
aly on second 
day. 


IstD. 


3d D 


4th,6thd 


Pustules, pea- 
sized. Mature 
and rupture. 


Scabs. Crusts. 
Scales. 


5 


CD 
m 


5" 


Umbilicated 


First on face. 


Temperature : 


p 


P 


p 


Falls 2 Q or 3° 


105° to 108° 

Secondary 

fever 


Gradual decline. 


o 
o 


o 


o 
o 

M 
© 

C 


Pulse : 


100 to HO. 
Full frequent. 


75 to 100. 


100 to 160. 
Hard and full 


q 

w 

S 

H 

ss 

Q 
H 
O 

oc 
>< 
% 

T3 
►3 

O 
g 


Nervous System: 


Chilliness. 
Vertigo, fron- 
tal headache. 

Pain in Joins- 


H 

r 
O 

SO 

O 

w 

£ 

O 


Headache. 
Delirium. 

Coma. 


Tongue : 


Red, at tip and 

edges. 


Thick, white 
coating. Sali- 
vation. 


> 
( Digestive Tract : 


Nausea. Vom- 
iting. Abdom- 
inal pains. 
Constipation. 


Constipation. 

Occasionally 

diarrhoea, 


Respiration: 


Labored. 


Short&labored 


Urine : 


Scanty. High- 
colored. 


Albuminous. 
Casts. 


Profuse . Pale. 


Throat: 


Sore throat. 


Reddish points. 

Inflamed. 

Dysphagia. 


Whitish points 

Hi'ly inflamed 

Dysphagia. 


Returns to normal 


Skin: 


Perspiration. 


Inflamed areolae. 

Swollen. 

Sickly odor. 


Tumefaction. 
Sickly odor. 


Reddish-brow n 
blotches. Cica- 
trices- 


Eyes: 


Congested. 


Conjunctivitis. 


Keratitis. 
(Edema. 


Recovery. 


Varieties : 


Distinct. Confluent, Hemorrhagic. 


Mortality : 


Distinct, 2 to 3 percent. Confluent, 50 per cent. 
Hemorrhagic, always fatal. 


Prophylactic : 


Vaccination, successfully performed. 



THE EEUPTION. 343 

commonly result from stenosis of the Eustachian tubes and 
catarrh of the middle ear, consequent upon tumidity and puru- 
lent infiltration of the epithelium. 

Tke Temperature. — The fever in small-pox is of the relaps- 
ing type. The temperature in the initial fever rises rapidly in 
an unbroken line to 104° Fahr. on the first day. During the 
second day it may rise to 105° Fahr., and by the third day it may 
xeach 106° Fahr. or even 107° Fahr. After the papules appear 
the temperature falls more or less rapidly, from the second to 
the sixth day of the eruptive period. Occasionally it reaches 
the normal, but generally it remains sub-febrile. During the 
suppurative fever it rises again to a height commensurate with 
the severity of the case. In confluent cases the secondary fever 
is marked by higher temperature and more active delirium than 
in distinct or moderate forms. 

In non-fatal cases the secondary fever lasts about a week, or 
until many of the pustules burst or dry into scabs and crusts, 
and defervesces by gradual lysis. 

The Pulse. — The pulse is increased in frequency during the 
initial fever, and ranges from 100 to 140 beats per minute. It 
diminishes fifteen or twenty beats during the eruptive stage, but 
rises again to 120 or 140, or even 160 during the suppurative 
stage. With defervescence it slowly returns to the normal. 

In severe confluent cases the heart-sounds are sometimes feeble 
and obscure, and the heart's action irregular and intermittent. 

Pericarditis occasionally occurs in conjunction with pleurisy. 
Ulcerative endocarditis is rare. 

The Respiratory System. — The respiratory movements are 
generally accelerated, and dyspnoea is often marked. Bronchitis 
is common in all well-marked cases. Catarrhal pneumonia may 
supervene upon bronchitis, and in persons predisposed to it, 
phthisis may be developed. Croupous pneumonia may occur 
during any period of the eruptive stage. Pleurisy setting in 
suddenly, and displaying a tendency to result in empyema, is not 
uncommon after the twelfth day in severe cases. 

The Eruption. — The eruption of small-pox appears, as a rule, 
on the third day, exceptionally it is met with as early as the sec- 
ond or not discovered until as late as the fifth, sixth, or even the 



344 LECTURES ON FEVERS. 

seventh day. It is characteristic of the disease, and is first seen 
upon the face, especially along the edges of the hair and about 
the chin and month. It soon extends to the neck, trunk and ex- 
tremities, and within twenty-four or forty-eight hours the entire 
body may be more or less covered by it. In young children it is 
often first observed upon the genitals. 

An intimate relation exists between the abundance of the 
eruption and the severity of the disease. A copious eruption, 
deep in color, and early becoming livid or petechial, indicates,, as 
a rule, a severe attack. Sometimes a roseolous rash resembling 
measles precedes the characteristic eruption. In confluent cases 
the eruption is dark and livid, and petechia are common. 

The course of the small-pox eruption is as follows : At first 
the lesion consists of small, isolated and rounded specks, which, 
soon become converted into papules. The papules are of a vivid 
red color, and measure from a third to two-thirds of a line in 
diameter. They are hard and feel like shot under the skin, and 
are frequently arranged in three's and five's in a crescentic man- 
ner. In hemorrhagic cases bright-red petechia occur upon the 
skin, coincident with the appearance of the papules. On the 
third day of the eruption the papules become conical in shape, 
and the apex of each pimple becomes vesicular, and gradually 
as the whole pimple takes this character, the apex becomes de- 
pressed, till on the fourth or fifth day of the eruption an umbil- 
icated vesicle is formed, containing a clear fluid and surrounded 
by a narrow, rosy areola. In confluent cases the vesicles as they 
form upon the papules, so crowd the surface as to run together, 
and, instead of serum, often contain a thin, brownish, ichorous 
fluid. In hemorrhagic cases they fill with a thin, sanguinolent 
fluid, instead of serum, and remain flat and flabby. 

The contents of the vesicle, which are at first transparent, 
gradually become whitish and milky, and by the sixth or seventh 
day they appear as pus — the vesicle is now transformed into a 
pustule. This process begins, as in all the metamorphoses of 
the disease, in vesicles of greatest age, those namely on the face 
and upper part of the body. As a general rule, the pocks are 
most numerous on the face, and next on the neck and limbs. 

The pustules enlarge until they attain the size of a pea, and 
the umbilication becomes lost. Their bases become hard and 
more or less broadened, and the whole of the skin, especially 



THE THROAT. 345 

about the face, becomes red and tumefied. About the eighth or 
ninth day of the eruption the pustules either break and discharge 
their contents, which harden into yellowish and ultimately 
brownish, irregular crusts, or else the entire envelope and con- 
tents desiccate and form brownish scabs. 

After a variable period of from a few days to five or six weeks, 
the crusts fall and leave a depressed, reddish-brown stain, which 
in time (five or six weeks) disappear. If there has been much 
destruction of the cutis, whitish depressed sccws called "pits" 
are formed, and the skin presents a "pock-marked" appearance. 

The Throat. — An eruption appears upon the pharyngeal, buc- 
cal, nasal, conjunctival and genital mucous membranes, simulta- 
neously with or slightly preceding the eruption on the skin. It 
begins with more or less vivid redness of the mucous membrane, 
followed by development of little red elevations. On the second 
or third day these red elevations assume the appearance of whit- 
ish, rounded points, which last generally about five days. 

Soon after the appearance of pustules in the mouth and throat, 
a true inflammation of the parts, as indicated by more or less 
sore throat and difficulty in swallowing, with swelling and ten- 
derness of sub-maxillary glands, sets in. Occasionally if the 
eruption extends to the larynx there is laryngeal distress and 
hoarseness. 

The Skin. — After the appearance of the eruption the skin 
becomes tense, red arid shining, and there is more or less inflam- 
mation and swelling of the sub-cutaneous cellular tissue. The 
swelling is greatest upon the face, where it commences about the 
fourth or fifth day of the eruption, increases for five or six days 
and then gradually diminishes as desiccation begins. In severe 
confluent cases the skin becomes thickened, swollen and hard, 
and assumes a darkish tint. And in hemorrhagic cases the face 
is swollen, purple or black, and bloody extravasations, which 
frequently dissect the cuticle from the skin, take place beneath 
the eruptive points. 

The physiognomy of a person ill with small-pox is somewhat 
peculiar. The tumid and closed lids, and the cedematous face 
thickly covered with pustules, render the features absolutely 
indistinguishable. 

The Digestive Tract. — The tongue is generally moist and 



346 LECTURES ON EEVERS. 

more or less furred, and is red at the tip and edges. In conflu- 
ent cases it is frequently enlarged. 

The appetite is, as a rule, lost during the course of the fever.. 
Sometimes it returns temporarily during the stage of eruptions. 

Thirst is commonly present, and is acute in proportion to the 
violence of the fever. 

Nausea and vomiting occur in the early stages, and are apt to 
be prominent symptoms. 

Dysphagia occurs in most cases, and is usually most marked 
in confluent cases. 

Constipation is very common in small-pox, and generally con- 
tinues throughout the disease. A slight diarrhea occasionally 
makes its appearance about the end of the first or second week. 
A severe diarrhea is almost always the sign of a dangerous com- 
plication. Colicky pains referred to the epigastric region are 
often complained of. 

The Urine. — The urine is diminished in quantity during the 
initial fever. After the secondary fever it is increased in quan- 
tity and of low specific gravity. Its color is at first darker than 
in health; during desiccation it is pale. Urea and uric acid are 
increased, and the chlorides are gradually diminished. In many 
cases albumen and tube-casts are present. Hematuria is occa- 
sionally encountered, and is always a grave symptom. It is 
commonly associated with other hemorrhages. 

The Genital Organs. — In non-pregnant females premature 
menstruation is apt to occur. 

In pregnant women there is a great tendency to abort, es- 
pecially in the latter months of pregnancy. 

In men variolous orchitis is not uncommon. 



LECTURE XXII 

Slliall-P0X.— ( Continued. ) 

At my last lecture I spoke of the nature, causation and course 
of small-pox. To-clay I propose to complete its history by con- 
sidering its anatomical changes, differential diagnosis and treat- 
ment. 

Morbid Anatomy. — The characteristic lesion of small-pox is 
the inflammation of the skin and mucous membrane constituting 
the eruption. 

The red spot which is the first step in the development of the 
eruption, is due to localized hyperemia of the papillary body. 
Soon the papillae, which are the seat of the congestion, become 
surrounded with cells, usually of larger size than those of nor- 
mal tissue. Most of these cells are swollen epithelia from the 
rete, that have undergone coarse granulation as a result of the 
hyperemia. The chief collections of these elements are seated 
mostly in the neighborhood of a hair follicle or sweat gland. 
As they accumulate they elevate the epidermis, and a little pa- 
pule appears at the point of redness. The papules which are 
formed at the red spot are thus due mainly to the changes in the 
rete Malpighii and in the capillaries. 

Following these changes an exudation, in which there are 
suspended delicate granules of coagulated albumen, and irregu- 
lar threads of coagulated fibrin, makes its appearance in an 
irregular cavity in the midst of the greatly widened rete, result- 
ing from destruction of the epithelia. As the exudation increases, 
a little vesicle is formed upon the summit of the papule. 

Frequently within a brief period after the first appearance of 

(347) 



348 LECTURES ON FEVERS. 

the vesicle, its center becomes depressed. This depression or 
umbilication is supposed to be due to the more rapid swelling of 
the peripheral cells. It is not observed in every vesicle, and dis- 
appears, as a rule, at the stage of suppuration. 

As soon as the vesicles are fully formed, pus-corpuscles, arising 
by endogenous formation from the epithelia traversing and 
bounding the cavity formed in the rete, appear. The vesicles 
are now changed to pustules. In healthy individuals the pus is 
thick and yellow, and the pus-corpuscles appear coarsely gran- 
ular; while in weakly, scrofulous persons the pus is watery and 
pale, and the pus-corpuscles are finely granular. 

The pustules as soon as they have matured, either burst or 
their contents dry, and form crusts. During desiccation on ac- 
count of the drying of the center, before the periphery of the 
pustule, a depression known as the umbilication of desiccation, 
of ten forms, at times in pocks previously non-umbilicated. If the 
suppuration has been the result solely of the destruction of the 
epithelia, no scar will be formed. But if a part of the connect- 
ive tissue has been transformed into pus, the result will be a 
cicatrix and pitting. 

The pigmentation of the skin which remains after the scabs 
have fallen, is due to imbibition of the coloring matter of the red 
blood-corpuscles which have transuded from the capillary loops 
in the papillae. 

On the mucous membrane the eruption is thickest and deepest 
in the respiratory tracts. 

The blood is of a dark color and deficient in fibrin. 

Congestion and parenchymatous changes, consisting of granu- 
lar or fatty infiltration of the internal organs are frequently 
observed. 

Extravasations of blood are found in almost all of the viscera, 
and in the skin and mucous membrane, in hemorrhagic cases. 

Differential Diagnosis.— The diagnosis of small-pox should 
be made out as early as possible, so that persons in contact with 
the patient may be vaccinated or re-vaccinated in time to prevent 
the diffusion of the disease. To be effective vaccination must 
be performed in time to reach the stage of areola — from seven 
to nine days — before any illness from small-pox occurs. 

As a rule, the diagnosis cannot be made with certainty pre- 
vious to the stage of eruption, and even then there is a possibility 






DIFFERENTIAL DIAGNOSIS. 349 

■of mistake. Generally, your safest course will be not to commit 
yourselves to a positive diagnosis until the vesicles are fully 
formed, up to which time there is but little danger from infec- 
tion. 

The principal diagnostic points are: the prominence of lum- 
bar pains and vomiting, the remission or cessation of fever as 
the eruption appears, the appearance of the eruption on the 
third day and first upon the forehead along the margin of the 
hair, the granular, hard, shotty papules, the umbilication of 
the vesicles, and the round, whitish or ashy spots on the throat 
and mouth. 

In the initial stage it is possible to mistake small-pox for ty- 
phus fever or meningitis. And during the first forty-eight hours 
the roseolous rash if present may be mistaken for scarlet fever 
or roseola. On the third day, when the papular rash is appear- 
ing, it may be mistaken for either measles, german measles or 
acne. At a later stage when the vesicles form it is possible to 
mistake it for varicella or chicken pox. 

Typhus fever can be easily differentiated from small-pox after 
the advent of the eruption. In small-pox the eruption makes 
its appearance upon the third day, while in typhus it does not 
appear until the fifth day, and is first seen upon the abdomen. 

Meningitis often simulates small-pox in the initial stage, as 
both diseases have photophobia, intense headache, nausea and 
vomiting occurring as prominent symptoms. In meningitis, 
however, the face is generally pale and anxious, while in small- 
pox it is flushed. The advent of the eruption will always dispel 
any doubt as to the correct diagnosis. 

Acne is always distinguished by the absence of the special 
constitutional symptoms of small-pox. 

Measles may be differentiated from small-pox by the early 
presence of catarrhal symptoms and by the absence of well- 
marked lumbar pain. The papules appear on the third day in 
small-pox and are, small, hard and distinct. They appear on the 
fourth day in measles, and are larger and flatter, and soon run 
together in crescentic outlines. In small-pox the temperature 
falls as the stage of eruption is reached, while in measles it con- 
tinues to rise as the eruption appears. 

Varicella or chicken-pox differs from small-pox in the almost 
complete absence of prodromes and in the rapid course of the 



350 LECTUKES ON EEVEKS. 

eruption. The rash appears on the second day, shows itself at 
once upon the face and trunk, and in a few hours becomes ves- 
icular. The vesicles are usually small, oval and remarkably 
transparent, and are apt to appear in successive crops. 

Prognosis. — The prognosis will depend largely upon the 
amount of the rash, for other things being equal, the more abun- 
dant the eruption, the greater the danger. 

The distinct variety is not usually fatal unless some complica- 
tion arises, the mortality being about two or three per cent among 
the non-vaccinated. In semi-confluent small-pox the mortality 
is about six per cent. In the confluent variety nearly one-half 
of the cases die. The hemorrhagic form is always fatal. 

The prognosis is greatly influenced by age. In early infancy 
and in old age, the ratio of mortality reaches its maximum. In 
intemperate people and in the over-worked and badly nourished, 
the prognosis is bad. Women, pregnant or in the puerperal 
state, and all persons unprotected by previous vaccination, run 
great risk when taken ill with small-pox. As in other epidemics, 
the mortality is greatest at the beginning and height of the epi- 
demic, and gradually declines as the latter draws to a close. 
Small-pox is, as a rule, more fatal in summer than in winter. 

Death is sometimes attributable to the intensity of the fever. 

Usually, if death occurs before the suppurative stage is reached, 
it is due to some complication involving, in the majority of cases, 
the throat and air passages. 

When not attributable to complications, a fatal termination is 
generally due to inability of the powers of the system to with- 
stand the depressing influence of the suppurative process. If 
death does not occur until the second week, it is oftenest due to 
exhaustion. 

The most dangerous complication of small-pox at the suppur- 
ative stage, is acute fatty degeneration of the kidneys. 

Unfavorable prognostics are, occurrence of the disease at the 
extremes of life, violent nervous symptoms during the initial 
stage, abundance of eruption, continuation of fever after appear- 
ance of eruption, occurrence of petechia and local hemorrhages 
cessation of salivation, typhoid delirium and other ataxic symp- 
toms. 

Treatment. — Prophylaxis. — The preventive treatment of 






PEOPHYLAXIS. 351 

small-pox consists in vaccination, properly performed, and of 
which I shall speak at my next lecture. Should your patient 
consult you too late to expect results from vaccination, you may 
administer either malandrinum or vaccininum internally as a 
prophylactic, usually with marked success. Drs. Eaue and 
Straube speak highly of the effect of malandrinum in the Phil- 
adelphia epidemic of 1880-81, and Drs. Kaczkowsky, Landell, 
Hughes and others concur in testifying to the great value of vac- 
cininum. Baptisia, hyclrastis, tartar emetic, sarracenia, cimici- 
fuga and sulphur, each and all have advocates of their prophy- 
lactic virtues in small-pox. 

To prevent the spread of the disease, every small-pox* patient, 
unless he can be thoroughly isolated at home, should be com- 
pelled to go to the municipal small-pox hospital. Every city 
and large town should have its small-pox hospital — built after 
the barrack system — particularly when the disease is prevailing 
as an epidemic. 

Every one in the house with the sick person should be vaccin- 
ated or re-vaccinated. The patient should be removed to an 
upper room, as far from other living and sleeping rooms as pos- 
sible, and absolutely no one should have access to him or her, 
except the physician and the nurse. The sick room should be 
large — not less than fifteen hundred cubic feet — and icell venti- 
lated, and the temperature should be kept below 60° Fahr. All 
unnecessary furniture, and all curtains and hangings which are 
liable to interfere with ventilation or retain the contagion should 
be removed from the room. Sheets should be hung up in the 
door and window ways, which should be kept constantly saturated 
with Piatt's chlorides or some disinfecting solution. Absolutely 
no intercourse should be had by the nurse with the members of 
the family and the outside world, until all danger of contagion 
has passed. 

Inmates of the house during the continuance of the disease, 
should refrain from visiting any school, church, theatre or other 
place of public assemblage. All letters before being sent from 
the house should be put in an oven and subjected to a temper- 
ature of not less than 250° Eahr. 

* All cases of small-pox occurring in the county, must be reported to the 
County Clerk; or, in cities, to the City Board of Health. 



352 LECTURES ON FEVERS. 

When attending a small-pox case, before entering the sick 
room, you should remove your overcoat and put on a rubber 
coat, which must be sponged with a weak carbolic acid solution, 
and hung up in another room on leaving the apartment. Before 
visiting your next patient it would be well to take a short drive 
in i he open air. 

Piatt's chlorides or a potassium cyanide solution (ten grains 
to the ounce of water), should be sprinkled upon the bed and 
about the room. 

All discharges from the nose and mouth should be received on 
cloths and immediately burned. The urine and faeces, and any 
scabs that may fall from the body, should be received in vessels 
partly filled with either a five per cent solution of carbolic acid 
or some other disinfectant, and afterwards buried a sufficient 
distance from the water supply. All bed and body linen should 
be thoroughly washed in a disinfecting solution before being 
removed from the room, and afterwards baked. 

After recovery the patient should be bathed in Piatt's chlorides 
solution, or in a weak solution of chloride of zinc — one part to 
three hundred — and fresh clean clothing put on. And at least 
two weeks should elapse after desquamation has taken place, 
before he may be allowed to again enjoy the society of his fam- 
ily and friends. In the event of death the clothing of the de- 
ceased should be sprinkled with strong carbolic acid, the body 
placed in an air-tight coffin, and privately interred, as early as 
possible. 

After recovery or death, the apartment should be fumigated 
by burning sulphur, thoroughly aired, cleansed and whitewashed. 
The bedding, all articles worn by the patient, and all the wear- 
ing apparel used by the nurse, should be either baked or if pos- 
sible immersed in some disinfecting fluid and then thoroughly 
boiled. The mattrass and pillows should be burned. 

Principal Remedies. — Baptisia, belladonna and veratrum vir. 
are oftenest indicated in the initial stage; vaccininum, malan- 
drinum, tartar emet. and thuja in the stage of eruptions; mercu- 
rius, malandrinum and lachesis in the suppurative stage; and 
sidphur in the stage of desiccation. 

Baptisia will be needed during the initial fever when there is 
considerable prostration, and an early tendency to decomposition. 
Veratrum vir. is called for when the fever is intense, the pain 



PRINCIPAL REMEDIES. 353 

in the back is severe, and the pnlse is very rapid. Cimicifuga 
shonld be thought of when the headache and backache are se- 
vere, and there is nausea and restlessness. Belladonna will be 
of service when the head and throat symptoms are severe, and 
there is a tendency to delirium. 

Tartar emet. is specially valuable during the eruptive stage. 
It is also of service during the stage of initial fever, if nausea 
and vomiting are very troublesome. After bryonia, it is the 
remedy for early bronchitis. Mercurius will have a favorable 
effect upon the suppurative process, if administered as soon as 
the secondary fever appears. It is always indicated when such 
symptoms as salivation, ulcerated sore throat, foetid breath and 
bloody diarrhea are present. Arsenicum iodide is preferable to 
either mercurius or tartar emet., after the pustules are formed, 
and there is a tendency to putrid decomposition. Apis will be 
of service when there is excessive swelling of the face with 
troublesome itching, and when either oedema of the glottis or 
nephritis threatens. Camphor, if the eruption suddenly disap- 
pears or suddenly becomes malignant. Lachesis or rhus iox., if 
a typhoid condition attains during the suppurative stage. Mu- 
riatic acid, or variolinum for malignant throat symptoms. 
Hepar sulph. for croupous laryngeal symptoms during the sup- 
purative stage, and for boils during the stage of desiccation. 
Mercurius cor. for the ophthalmia, and after apis for the paren- 
chymatous nephritis. Bryonia and Icali bich. for bronchitis. 
Phosphorus or tartar emet. for pneumonic complications. 
Sulphur when there is furious itching during desquamation. 
Kali sulph. to hasten the removal of the scabs. Cinchona for 
excessive debility and prostration after a severe attack. 

Malandrinum, tartar emet., arsenicum and phos. acid are often- 
est used in confluent cases. Crotalus, ammonium carb. and 
lachesis are the remedies most frequently administered in the 
hemorrhagic variety. 

Leading* Indications. — The guiding symptoms for the differ- 
ent remedies may be compiled as follows: 

Ammonium cart). — Hemorrhagic tendency. Putrid sore 
throat (mur. acid). Dyspnoea from retrocession of eruption. 
Adynamia. 

Apis mel. — High fever with chilliness from the slightest 



354 LECTURES ON FEVERS. 

movement. Erysipelatous redness and swelling with stinging, 
burning pains in skin and throat. Dry ulcers on the tonsils and 
palate. Nausea and vomiting with soreness of the pit of the 
stomach on pressure {bry.). Suppression of urine {hyos., opium); 
albuminuria (phos. acid). Dyspnoea with great restlessness and 
trembling (ars. alb.) 

Arsenicum. — Great sinking of strength (verat alb.) with 
burning heat and extreme restlessness {camphor). Frequent, 
small, trembling pulse. Irregular action of the heart, absence 
of the second sound. Tongue red, dry and cracked. Dryness 
of the mouth with violent thirst, drinks often, but little at a time 
{bell., opp. bry.). The eruption is intermixed with petechias 
{rhits). The pustules sink in and their areolae grow livid (lack.). 
Mild delirium with convulsive twitchings of the tendons. Dysp- 
noea, constantly changing position. Violent diarrhea. Typhoid 
symptoms. 

Baptisia. — Dull, stupefying headache {gels.). Nausea fol- 
lowed by vomiting. Great prostration with excessive pain in the 
lower part of the back. The eruption is more marked in the 
throat than upon the skin. Foetid breath with profuse salivation 
{mere). Dark, red face with besotted expression. Dyspnoea 
and great nervous restlessness. Dysenteric stools. Offensive 
secretions. 

Belladonna. — High fever and sore throat. Severe head symp- 
toms with delirium. Eyeballs red and injected with intolerance 
of light. Pain in the back as if it would break. Throbbing of 
the carotids {gels.). Intense swelling of the skin and mucous 
membrane (apis). Violent tonsilitis with stitching pain. Diffi- 
cult deglutition; fluids swallowed return through the nose {kali 
bicli., lach.). Dry, spasmodic cough, worse at night {hyos.). In- 
voluntary micturition and defecation. Jerking of the bedclothes. 
Starts as if in affright on awaking or during sleep (ars.). 

Bryonia. — Great prostration with coldness or mixed chill and 
heat. Stitches, soreness and dry feeling in the throat. Extreme 
sensitiveness of the epigastrium to the touch (apis). Nausea 
and f aintness on rising. Eestless sleep with moaning and with 
chewing motions {bell). Obstinate constipation. Chest symp- 
toms. 



LEADING INDICATIONS. 355 

Camphor. — Sudden and great sinking of strength with cold- 
ness of the surface (ars.). Sudden collapse from exhaustion of 
the vital forces (verat alb.). The eruption suddenly disappears 
and the pustules appear to dry up rapidly. Dyspnoea with sen- 
sation of constriction around the throat with hot breath. Smal], 
weak, scarcely perceptible pulse (carbo. veg.). Rattling in the 
throat; involuntary evacuations. 

Cantharis. — The eruption assumes the hemorrhagic form. 
Tonsilitis with inability to swallow. Thirst with aversion to all 
fluids (bell). Dysuria and bloody urine. Albuminous urine 
with cylindrical casts (ierebinthina). Hemorrhages from the 
nose, mouth, intestinal canal, urinary and genital organs. 

Carbo. veg. — Coldness of the breath and tongue (verat. alb.). 
Excessive prostration (ars.). Internal burning, wants to be 
fanned (ars.). Livid, purple appearance of eruption (lach.). 
Rattling in the throat with complete loss of vital power. Thread- 
like, scarcely perceptible pulse. Ecchymoses. 

Cimicifuga. — Dull, heavy, aching pain in the small of the 
back, relieved by rest, increased by motion (bry.). Great mus- 
cular soreness (am., bry.). Pricking, itching heat of the skin. 
Severe pain in the head and eyeballs, aggravated by motion 
(bry.). Redness of the fauces and palate. Obstinate sleepless- 
ness (eoff., opium). Delirium resembling delirium tremens 
(digit). 

Gelsemiiim. — Great exhaustion and drowsiness. Feeling as 
of a band around the head above the ears (mere). Itching of 
the head, face and neck. Nausea and vomiting with weak, 
scarcely perceptible pulse. Trembling and complete loss of 
muscular power. Predominance of nervous symptoms. 

Hamamelis. — Tearing pains in the small of the back. Con- 
stipation with severe frontal headache. Hemorrhages from all 
parts. 

Hepar sulpb. — High fever with redness of the face and 
hoarseness. Stitching pains extending from ear to ear when 
swallowing. Hoarse, croupy cough. Swelling and suppuration 
of the glands. Unhealthy skin, slight injuries induce suppura- 
tion and ulceration. 



356 LECTURES ON FEVERS. 

Hydrastis. — Dull, heavy, dragging pain and stiffness in the 
lumbar region. Faintness and prostration. Great swelling, red- 
ness and itching of the skin. Excessive soreness of the throat, 
which is studded with dark pustules. Obstinate constipation. 
Is said to prevent pitting when used both internally and exter- 
nally. 

Hyoscyamus. — Late appearance of the eruption, causing great 
nervous excitement. Constant desire to get out of bed. Red, 
sparkling, staring eyes [bell). Constrictive sensations in the 
throat with inability to swallow (bell). Involuntary stools at 
night (ars., rhus). Retention of urine (opium). Grating of 
the teeth (apis, hell. ). Hyperesthesia of the skin. Brown spots 
or gangrenous vesicles on the body. 

Lacliesis. — Headache mostly in the forehead with nausea and 
chilliness. Aggravation of all the symptoms after sleep. Stu- 
por and muttering delirium (apis). Dry, red or black, cracked 
and bleeding tongue (ars.). Oppression of the chest. Solids 
swallow better than liquids. Irregularity of heart beat (digit) . 
Stitches in the throat when swallowing. Suppuration of the 
glands of the neck. Destructive decomposition of both fluids 
and solids. Passive hemorrhages of dark fluid blood. Specially 
adapted to a typhoid condition during suppurative stage. In 
intemperate persons. 

Malandrinum. — Useful as a preventive, and when the secre- 
tions are very offensive. It almost invariably lessens the sec- 
ondary fever. (Malandrinum is attenuated lymph from the 
horse-pox vesicle. ) 

Mercurius. — Great restlessness, weariness and prostration. 
Swollen, soft, flabby tongue, taking the imprints of the teeth.. 
Putrid odor from the mouth (bapt). Ulcerated throat with 
profuse salivation. Diarrhea or dysentery with tenesmus. Per- 
spiration without relief (ars., opp. gels.). Adapted to the sup- 
purative stage. 

Opium. — Complete loss of consciousness with slow stertorous 
breathing. Face, dark red, hot and bloated (bell). Bed feels 
hot, can hardly lie on it. Difficult, intermitting breathing as 
from paralysis of the lungs (lye, tart emet). Retention of 
urine. Picking at the bedclothes. In children and old people. 

Phosphorus. — Stupefying headache with acuteness of smell 



LEADING INDICATIONS. 357 

(bell.). Difficulty of hearing, especially of the human voice. 
Soreness of the stomach and abdomen to the touch. Pain in the 
back, as if broken (rhus). Extensive petechia or hemorrhages. 
Bloody pustules. Pneumonic complications ( lye. ). Small, quick, 
easily compressed pulse. Dry, immovable tongue, cracked and 
covered with sordes (ars., verat. alb.). After over-doses of cam- 
phor. 

Phosphoric acid. — Great fear of death. Headache, worse 
from the least shaking or noise (bell). Dryness of the mouth 
and throat without thirst {mix). Involuntary stools; watery 
diarrhea. The pustules don't fill with pus, but degenerate into 
large blisters which burst and leave the surface excoriated. Con- 
fluent small-pox. 

Rhus tox. — Great restlessness and uneasiness (ars.). Bruised 
pains in the small of the back when sitting still or when lying; 
better from motion. Active delirium and great prostration. 
Vivid, troublesome dreams of excessive bodily exertion. Dark, 
livid redness of the cheeks. Redness of the tip of the tongue 
in the shape of a triangle. Sordes on the lips and teeth. Hem- 
orrhage from the mucous surfaces and into the pustules. The 
eruption shrinks and looks livid. Erysipelas with great burning. 
Glandular swellings. Confluent small-pox with typhoid symp- 
toms. 

Sarracenia. — Is said to have curative or prophylactic virtues 
in this disease. 

Sulphur. — During the stage of desiccation, and when the dis- 
ease pursues an irregular course. 

Tartar emet. — Stupefying headache with pressure from with- 
out inwards, in the forehead and root of the nose. White, pasty 
coating on the tongue. Tongue red in streaks and dry in the 
middle (rhus). Continuous, anxious nausea (ipecac). Watery, 
slimy, bloody diarrhea. Great rattling of mucus in the chest. 
Excessive restlessness. The pustules, after drying, leave bluish- 
red marks. Typhoid pneumonia. 

Thuja. — Boring, stitching pains in the forehead, temples and 
over the eyes. Conjunctivae inflamed and red like blood. (Edem- 
atous swelling of the face (apis). Marked, dark red areolae 
around the pustules. Rawness and dryness in the throat. Burn- 
ing from the small of the back to between the shoulders (phos.). 



358 LECTURES ON FEVERS, 

Painful drawing in the sacrum, coccyx and thighs, while sitting.. 
Specially adapted to the stage of suppuration. 

Yaccininum. — Great fear of taking small-pox, is said to be a 
characteristic. Has been used with success in all stages. (Yac- 
cininum is attenuated lymph from the cow-pox vesicle. ) 

Yariolinum. — Especially when throat symptoms are promi- 
nent. Is said to cause the disease to run a mild course, and 
prevent scarring. ( Yariolinum is attenuated lymph from the 
small-pox vesicle.) 

Yeratrum vir. — Severe frontal headache with vomiting. Sud- 
den spasms with nausea, vomiting and utter prostration. Ked 
streaks in the middle of the tongue ; yellow edges. Burning in 
the fauces with constant inclination to swallow. Intense fever 
with irregular, hard, frequent pulse. Oppression of the chest 
with slow, labored breathing. Profuse sweat. Itching and burn- 
ing of the skin. In plethoric individuals. 

HYGIENIC AND DIETETIC TREATMENT. 

The general management and nursing of the small-pox patient 
are highly important. The sick room should be large, well-ven- 
tilated, and moderately darkened. The temperature of the 
apartment should be kept below 60° Fahr., which in winter 
should be heated by an open fireplace rather than by hot air. 
Carpets and all unnecessary articles of furniture should be re- 
moved. The strictest attention should be given to cleanliness 
and to the use of disinfectants. Piatt's chlorides, a solution of 
carbolic acid or of potassium permanganate, should be sprinkled 
freely over the bed and on the floor. Cloths wet in the solution 
should also be suspended in the room. The physician or nurse 
should wash the hands in some disinfecting fluid, on every oc- 
casion for touching the patient. 

The body may be sponged with or bathed in tepid, carbolized 
water as often as proves grateful. In severe or confluent cases, 
the continuous warm bath as practiced in Yienna renders excel- 
lent service. When the pustules rupture, carbolized baths are 
frequently effectual in relieving the itching. During desquama- 
tion, warm baths every two or three days followed by oiling the 
body, are useful in removing the crusts. When the pain from 
the distension of the vesicles is intense, the parts may be soaked 
in hot water, or hot water compresses applied for fifteen or twenty 



HYGIENIC AND DIETETIC TREATMENT. 359 

minutes, and the vesicles punctured to allow the escape of their 
contents. To correct the offensive odor during the suppurative 
stage, the surface may be frequently bathed and the throat gar- 
gled with a weak solution of potassium permanganate (five or 
ten grains to a quart of water), or Piatt's chlorides (one part to 
ten or fifteen of water). In confluent cases where the blebs 
break, marked benefit is derived from dusting the raw surface 
with a powder of starch and zinc oxide. 

When the mucous membrane of the throat is highly inflamed, 
considerable relief is experienced from holding small pieces of 
cracked ice in the mouth. A sponge wrung out in hot water, 
repeated as it cools, often relieves the intense pains in the back. 
Hot cloths, as hot as can be borne, may be applied to the head 
when headache is severe. Hot water compresses may also be 
resorted to when there is considerable oedema of the face and 
eyelids. The general smarting pain, frequently experienced 
over the whole of the cutaneous surface, may often be relieved 
by inunctions with mildly carbolized vaseline. The position of 
the patient in bed should be frequently changed so as to avoid 
constant pressure on the back or nates. 

The treatment of the eruption with a view to preventing scar- 
ring and disfiguration, is of the greatest importance. Usually 
the best results are obtained from careful evacuation of the ves- 
icles by means of a fine needle, and the constant use of carbolized 
water dressings. And yet you will do well to remember that no 
measures will prevent the occurrence of a distinct cicatrix when- 
ever the integrity of the papillary layer of the corium is de- 
stroyed. If the pustules remain superficial the pitting will be 
slight, but if the true skin becomes involved, pitting will occur 
in spite of treatment. 

The diet consists principally of rice, corn starch and milk 
which may be taken ice cold if desired. After three or four 
days beef tea, chicken broth, mutton broth, or yolks of eggs 
beaten up in milk, may be alternated with milk. Water may be 
administered freely, and if preferred may be given cold. 

Stimulants should be given in cases of great prostration, and 
when extensive suppuration threatens. They may be given alone 
or in the form of wine whey (p. 194), or brandy punch (p. 306). 

If constipation is present it may be relieved by the adminis- 
tration of enemas. 



LECTUEE XXIII. 

Varioloid and Vaccination. 

To-day, before directing your attention to varioloid or modified 
small-pox, I will give a passing notice to cow-pox, vaccinia in 
the human subject, inoculation and vaccination. 

Cow-Pox. 

Definition. — Cow-pox is a specific eruptive disease, occurring 
chiefly on the teats and udders of milch cows, and is character- 
ized by the development of papular, vesicular and pustular le- 
sions. It may appear either sporadically or as an epizootic, and 
is mainly communicable by actual contact. 

Synonyms. — Kine-pock. Yaccine disease. 

History. — Cow-pox has prevailed from time immemorial, but 
is not as prevalent now as formerly. It may prevail at all sea- 
sons of the year except midsummer, but is most common during 
the months of May and June. 

Etiology. — It may be induced in cows in either of three ways: 
1. By inoculation with the virus from affected cows. 2. By in- 
oculation with the virus of horse-pox. 3. By inoculation with 
the virus of small-pox. 

Clinical History. — After an incubation of from three to four 
days the parts become hot and tender, and a few small, red pa- 
pules appear on the base of the teats and udder, which in three 
or four days change into vesicles and become umbilicated. The 
vesicles are usually pea-sized, present a glistening appearance, 
and are generally oval on the body of the teats and udder, but 

(360) 



VACCINIA. 361 

circular on the base and neck of the teats. On the eighth or 
ninth day a pale, rose-colored areola appears around the vesicle, 
which steadily enlarges until the tenth or twelfth day, when it 
has attained the width of nearly half an inch. The lymph in the 
vesicle becomes opaque about the twelfth day, and desiccation 
takes place leaving brownish-black crusts which fall off in about 
three weeks. 

Horse-pox. — Horse-pox is a similar disease to cow-pox, and 
will produce vaccine disease in the cow. Its eruption is more 
generalized than that of cow-pox, and appears on the trunk and 
limbs as well as upon the nasal and buccal mucous membranes. 

Vaccinia (in man.) 

Definition. — Vaccinia is an affection produced by the intro- 
duction into the human system of the virus of cow-pox, or of 
humanized virus — a few removes from the cow-pox. It is conta- 
gious only by inoculation, and possesses valuable protective 
properties against smali-pox. 

Synonym. — Vaccine disease. 

Clinical History. — Between the third and fourth clays after 
the introduction of the virus into the tissues of a previously un- 
vaccinated subject, a light reddish, pin-head sized papule arises 
at the point of operation. On the fifth day an oval or circular 
vesicle of a bluish-white color, and surrounded by a yellowish- 
white margin makes its appearance. This vesicle increases in 
size and becomes umbilicated on the sixth day. It is now sur- 
rounded by a very narroAV ring of inflammation — the areola. On 
the eighth day the vesicle reaches its highest degree of develop- 
ment and is about one-third of an inch in diameter. It is filled 
with a thin, transparent fluid, which becomes opalescent on the 
ninth day. The contents of the typical vesicle are auto-inocu- 
lable. ( Between the fifth and eighth days is the time to take 
lymph for the purpose of vaccination). The areola enlarges 
during the ninth and tenth days, and attains its maximum size 
of about two inches in diameter. It is of a brilliant scarlet or 
dark red color, and is most intense at the edge of the vesicle. 
The skin and cellular tissue become hardened and tumefied; 
heat, itching and tenderness are usually marked. The contigu- 
ous lymphatic glands are apt to be irritated and swollen. 



362 LECTURES ON FEVERS. 

After the tenth or eleventh day the disease begins to subside. 
The red areola fades, the swelling and induration of the tissues 
abate, and the pustule — for such it has become — either ruptures 
or begins to dry up. Desiccation of the pustule progresses rap- 
idly, so that about the fourteenth or fifteenth day a firm, hard, 
dark-brown or mahogany-colored scab has formed, having a cen- 
tral depression and no areola of inflammation. The scab grad- 
ually separates from the tissues and falls off about the eighteenth 
or twenty-first day, leaving a circular or oval depression or cica- 
trix, studded with several minute pits or dots. The cicatrix is 
at first of a deep red or purple color, but fades gradually until it 
finally assumes a dead-white color. The shape and size of the 
scar, crust and vesicle correspond with the scarification, and will 
be circular or irregular, according as the latter is circular or 
irregular. Although usually indelible, many of the most per- 
fect cicatrices disappear entirely as life advances. 

The constitutional disturbances are usually very slight. The 
febrile reaction about the eighth day differs in different subjects, 
and is generally more severe when bovine virus, procured re- 
cently from the cow, is used, than when humanized virus is in- 
troduced. 

Individuals possess different degrees of susceptibility to vac- 
cinia at different times. Children are usually more susceptible 
than adults. 

Irregularities. — The deviations from the regular course of 
development of vaccinia may be either normal or abnormal. 

1. The Normal Irregularities. — Retardation in the appearance 
of the vesicle is not uncommon. The vesicle may not show 
itself until the sixth or eighth day, and yet the disease may 
afterwards run a normal course, with no diminution of protective 
power. 

When vaccination is performed during the incubation periods 
of either measles, scarlet fever or chicken-pox, and the vesicles 
do not reach the stage of areola, before the symptoms of the 
particular disease become manifest, the areola will not form 
until the disease has run its course. 

Old vaccinations, apparently unsuccessful, have not infre- 
quently been revived by recent vaccination. 

2. The Abnormal Irregularities. — Vaccinia is spurious when 
it assumes any of the following aspects: 



COMPLICATIONS. 363 

a. — The appearance of red, pea-sizecl tubercles at the seat 
of vaccination. 

b. — The development of acuminated instead of umbilicatecl 
vesicles, with marked itching. Instead of containing clear lymph, 
the vesicles contain a straw-colored fluid. The scabs fall off as 
early as the tenth day. 

c. — The formation of a bulla or bleb, instead of a papule or ves- 
icle. 

d. — The appearance of herpetic vesicles in crops, about the 
third day, preceded by shivering and accompanied by intolerable 
itching. 

e. — The sudden rupture and formation of ulcers, in vesicles, 
which, up to the eighth or ninth day, have apparently run a nor- 
mal course. 

Complications. — Vaccinal eruptions are not uncommon after 
the ninth day of vaccine disease. Roseola, erythema multiforme 
and lichen are oftenest met with, and are generally of a benign 
character. 

Erysipelas is comparatively rare, but if it does occur during 
the course of development of the vaccine vesicle, it completely 
destroys the protecting power of the vaccination. The cause of 
the development of erysipelas during vaccinia is frequently 
found in the constitution and habits of the vaccinated individual. 

Eczema. — In eczematous subjects, eczema is often aroused, 
and is apt to interfere with the development of the vesicle, and 
may render the vaccination non-protective. It is advisable, 
therefore, not to vaccinate an individual suffering from any form 
of skin disease, particularly if it is vesicular in character. 

Syphilis may be transmitted by vaccination with impure hu- 
manized virus, or by using an infected instrument. In such 
cases the blood of the syphilitic individual must have become 
mixed with the lymph, or else a vaccine crust from a syphilitic 
person must have been used. For pure, unmixed vaccine lymph 
cannot communicate syphilis even though taken from a syphi- 
litic patient. Inherited syphilis not infrequently develops after 
vaccination, even when animal virus is used. 

Glandular Swellings. — Inflammation and suppuration of con- 
tiguous lymphatic glands sometimes occur, and are annoying, 
though by no means dangerous complications. 



364 LECTUKES ON FEVEES. 

Inoculation. 

Definition. — Inoculation is the now obsolete method of ren- 
dering small-pox poison innoxious, by introducing variolous 
lymph, taken on the fifth or sixth day of the eruption, into the 
arm, and producing a contagious disease — capable of transmit- 
ting small-pox to others — which passes through the regular stages 
of small-pox in a mild and rapid course. 

History. — Inoculation was employed in China and India as 
early as the eleventh century. It was first practiced in Constan- 
tinople in 1700. Drs. Simoni, Kennedy and Pylarini published 
an account of it in the English journals in 1714-15. Lady Mon- 
tague, whose son was inoculated at Constantinople in 1717, in- 
troduced the practice into England, by inoculating her daughter 
in the year 1721. It was first performed in this country in 1721 
by Dr. Boylston, of Boston, at the suggestion of the Rev. Cotton 
Mather. At the beginning of the present century it fell into 
disuse upon the advent of vaccination. 

Clinical History. — On the second day after the introduction 
of the lymph, a minute orange-colored spot is perceptible by the 
aid of a magnifying glass, at the point where the operation is 
performed. On the third or fourth day after the operation, the 
punctured point becomes hardened, and a small, umbilicated 
vesicle seated upon an inflamed base makes its appearance. On 
the fifth day the vesicle is well developed, and a narrow, rosy 
areola is formed. On the sixth day the parts become hardened, 
hot and painful. In the evening of the seventh or morning of 
the eighth day the patient is seized with rigors, headache and 
vomiting. Febrile movement follows, and a variolous eruption 
soon makes its appearance on various parts of the body. Usually 
not more than twenty or thirty vesicles are formed. Sometimes 
not more than three or four papules can be discovered. Two hun- 
dred vesicles would form a maximum crop. After the eighth day 
the inflammation in the arm spreads with great rapidity, and a 
number of minute confluent vesicles appear upon the now large 
aiM irregular areola. On the tenth day the arm appears red, 
tense and shining, and the pustule, if it has not been opened, now 
bursts and discharges copiously. The disease now begins to 
subside, the areola fades, and desiccation progresses rapidly. 



VACCINATION. 365 

Surgery of Inoculation. — Inoculation is performed by intro- 
ducing a minute portion of variolous lymph, taken from a fifth 
day vesicle, into the arm at the insertion of the deltoid, by means 
of a lancet. 

Mortality. — The ratio of mortality after inoculation is about 
one per cent. 

Vaccination. 

Definition. — Vaccination is the introduction of bovine or hu- 
manized virus into the skin of the human subject. It is the 
method usually employed to induce vaccinia as a protective 
against small-pox. 

History. — The history of vaccination dates from the latter 
part of the last century. It is intimately connected with the 
life of Jenner, who was born in 1749 at the vicarage of Berkley, 
in Gloucestershire, and died in 1823, full of years and honors. 

On the fourteenth day of May, 1796, Jenner made his first 
vaccinnation. It was performed on a boy named James Phipps, 
eight years of age. The lymph was taken from the hand of 
Sarah Milnes — a milk-maid who had been infected by her em- 
ployer s cows — and inserted by two superficial incisions. The 
patient passed through the disease satisfactorily and was tested 
on the first day of July following, by small-pox inoculation, 
without effect. 

Vaccination was introduced into this country by Dr. Water- 
house of Boston, in July, 1800, with virus received from Jenner. 
It was introduced into France the same year, reached India in 
1802, and rapidly came into general use. 

The principle of vaccination introduced by Jenner is receiving 
new development, and is now being applied by Pasteur to the 
extinction of other diseases. 

Prophylactic Influence. — The position of the medical profes- 
sion on the protective power of vaccination against small-pox is, 
that in the majority of cases, those who have gone regularly 
through vaccinia are saved from any future attack of small-pox, 
and that in the majority of cases — where it does not prevent — it 
so modifies the disease as to deprive it of all danger to life. 

Marson's table, giving the results of observations on nearly 



366 LECTURES ON FEVERS. 

five thousand post-vaccinal cases of small-pox scattered over a 
period of twenty years, well exemplifies this protective power. 

Classification of patients No. of deaths. Per cent 

affected with small-pox. in each class. 

1. Unvaccinated 35. 

2. Stated to have been vaccinated, but having no 

cicatrix 23.57 

3. Vaccinated 

a. Having one vaccine cicatrix 7.73 

b. Having two vaccine cicatrices 470 

■c. Having three vaccine cicatrices 1.95 

d. Having four or more cicatrices 0.55 

e. Having well-marked cicatrices 2.52 

/. Having badly-marked cicatrices 8.82 

4. Having previously had small-pox 19. 

The Yirus. — In this country vaccination with bovine or heifer- 
transmitted cow-pox virus, is the rule. The current stocks * 
are either bovine virus or humanized virus, one or a few removes 
from the cow-pock. The fewer removes the lymph undergoes, 
the more marked the freedom from post-vaccinal small-pox, after 
its use. Vaccine virus which has gone through many successive 
transmissions loses considerable of its prophylactic influence. 
The more frequent occurrence and greater fatality of post-vacci- 
nal small-pox during the last twenty years, is doubtless due to 
the use of long-humanized virus. Erysipelas occurs with greater 
frequency after the use of humanized lymph, than after care- 
fully selected bovine virus. 

Quill slips and ivory points are the favorite methods of pre^ 
serving animal or bovine vaccine, while the crust is the usual 
method of preserving humanized vaccine. 

For several years past I have been accustomed to vaccinate 
my private patients with bovine virus, using the well-prepared 
ivory points. The points are always convenient and cleanly, and 
the bovine virus has in every case given satisfaction. 

Period of Performance. — As a general rule, if the health of 
the child permits, the operation should be performed about the 
age of three months, thus anticipating the period of dentition. 

*Forafull account of the method of obtaining and storing virus, consult 
Harding n "Essentials of Vaccination." 



BEVACCINATION. 367 

Under clanger of infection, however, no age should be exempt 
from vaccination. 

The following comparative table of small-pox death-rates 
among vaccinated and nnvaccinated respectively, for one year 
ending May 29, 1881, given by Dr. Buchanan, of London, shows 
the value of infant vaccination, and the necessity for re-vaccina- 
tion. 

Death-rate per million among Death-rate per million 
Ages of patients. the vaccinated. among the unvaccinated. 

All ages 90 3,350 

Under twenty years. . . 61 4,520 

Under five years 40J 5,950 

Re-vaccination. — All persons who have been vaccinated in 
infancy should undergo re-vaccination as they approach adult 
life. The best time for re-vaccination is from fifteen to eighteen 
years of age. All doubtful primary vaccinations should be put 
to the test of a re-vaccination. Under danger of infection, re- 
vaccination should be performed, even if only a short time has 
elapsed sijace a previous inoculation. Dr. Martin reports that 
he has succeeded in re-vaccinating with bovine virus in seventy- 
three per cent of the cases. Severe constitutional symptoms 
occur much more frequently after a re- vaccination than after a 
primary vaccination. 

Surgery of Yaccination. — The preferable method of insert- 
ing the virus is by scarification, which consists in making a 
number of single or double scratches or cross scratches. A 
small, wedge-shaped lancet is all-sufficient for the purpose, but 
my preference is to use for each case a separate ivory point 
charged with lymph. Before inserting the point it will be nec- 
essary to ""revive" the lymph with a minute quantity of cold' 
water. The vaccination should not be performed hurriedly; the 
lymph must be worked into the wound until dry. In scarifying 
you should go deep enough to cause a slight oozing, but not a 
flow of blood. 

The usual place for performing vaccination is upon the left 
arm, at the insertion of the deltoid muscle, and along its poster- 
ior border. The several scarifications or punctures — if valvular 
punctures are resorted to — should be made at some little distance 
from each other. When vaccinating by separate punctures — per- 



368 LECTURES ON FEVERS. 

formed by Introducing, at an angle of about 45 degrees, beneath 
the cutis a well-charged needle or lancet in such a way that the 
lymph may gravitate into the wound — you should make such punc- 
tures as will produce at least four separate good-sized vesicles, 
not less than half an inch apart. After a perfect vaccination the 
united area of the cicatrices should amount to one-half a square 
Inch. It is usually considered advisable to examine the vesicle 
on the eighth or ninth day of the disease, and also the cicatrix,, 
as soon as it is formed. 

Varioloid . 

Definition. — Varioloid Is an acute contagious disease, due to- 
the small-pox contagion, occurring only in individuals who have 
been successfully vaccinated, or who have already had the nat- 
ural or inoculated disease. It runs through the same stages a& 
small-pox, but is of shorter duration, and may abort at any period. 

Synonym. — Modified small-pox. 

Etiology. — The etiology of varioloid is the same as that of 
small-pox. The virus of varioloid is capable of producing in 
persons unprotected, a severe and fatal form of small-pox. 

Clinical History. — The initial symptoms are of the same 
character, and are often as marked, as in cases of natural small- 
pox. Not infrequently in children the attack begins with slight 
fever attended with headache and languor, which subsides in two 
or three days, as soon as the eruption appears. The eruption is 
far less copious than in the regular form of the disease, and 
passes more rapidly through its successive changes. The small 
red spots first appear, usually on the forehead, and are immedi- 
ately followed by papules, which within twelve hours may be- 
come converted into vesicles. The vesicles rapidly increase in 
size, and are sometimes umbilicated. On the third day they 
become changed into pustules, without any tumefaction of the 
cutaneous surface. Secondary fever seldom appears, unless the 
rash is extensive. When present, it is usually slight and gener- 
ally disappears within twenty-four or forty-eight hours. On the 
fifth day the pustules begin to dry up, and desiccation may be 
completed by the seventh day. 

The scabs begin to fall as early as the eighth day of the erup- 



CHART. 

CHAET XV.— Varioloid. 



369 



Nature : 


Contagious 


Stages : 


Invasion. 


Eruption. 


Suppuration. 


Desiccation. 


Duration: 


2 to 3 days. 


3 days. 


2 days. 


2 days. 


Eruption: 


Erythema of- 
ten present. 


1st D. 2ndD. 


3rd D. 


Pustules limited. 
Small areola. 


Begins on 5th 

day. Com- 
pleted on 7th 
day. 


•a 


<! 

o 

CO 

ft 
ft 

00 


CO 

ft 

CO 


Umbilicated 


Throat: 


Sore throat. 
Dysphagia. 


Slight eruption. 


Pharyngitis. 


a 

M 
CO 
CO 

1-3 
O 
S5 

C 
t=i 

w 
-< 

o 
K 
oa 


Temperature: 


100° to 103° 


m 

d 
w 

no 

5 

o 
o 

CO 
g 
H3 

O 

CO 


Slight secondary 
fever. 


Nervous System: 


Chill. Head- 
ache. Pain in 

loins. 


Headache. 
Lassitude. 


Pulse: 


Increased in 
frequency. 


Slightly quick- 
ened. 


Cutaneous 
Surface. 


Perspiration. 


Unbearable itch- 
ing. Sickly odor. 


Respirations 


Slightly accel- 
erated. 


Slightly acceler- 
ated. 


Bowels: 


Constipated. 


Constipated. 


Urine: 


Scanty. 


Darker than nor- 
mal. 


Eyes: 


Injected. 
Lachrymation 


Injected. 
Photophobia. 


Injected. 
Slight cedema. 


Stomach: 


Nausea. 
Epigastric ten- 
derness. 


No tenderness. 


Slight tender- 
ness. 


Return of 
appetite. 


Prognosis: 


Generally favorable. 


Recurrence : 


Varioloid seldom recurs. 


Incubation: 


From one to three weeks. 


Influence: 


It reproduces the contagion of, and protects against, small-pox. 



370 LECTURES ON FEVEES. 

tion, and desquamation is usually completed about the twelfth or 
fourteenth day. Reddish spots or blotches are left, which grad- 
ually disappear without leaving cicatrices. 

Duration. — The duration of varioloid varies from ten to 
twenty days. 

Differential Diagnosis. — The differential diagnosis of vario- 
loid is the same as that of small-pox. 

Yarioloid differs from small-pox, with which it may be con- 
founded, in the rapid development and decline of the eruption, 
in the small number of pustules, and in the short time required 
for the formation and separation of the crusts. 

Prognosis. — The prognosis is generally good. Exceptionally 
the disease proves fatal in a ratio of from five to ten per cent. 

Treatment. — The treatment for varioloid is essentially the 
same as for mild small-pox (p. 350). 



LECTUEE XXIV. 

Chicken-Pox. 

Definition. — Chicken-pox may be defined as an acute epi- 
demic contagions disease, occurring for the most part in children, 
characterized by an eruption of oval, isolated, hemp-seed sized 
vesicle, appearing in successive crops, accompanied by a very 
moderate constitutional disturbance. It occurs only once in the 
same individual. The period of incubation is eight days. 

Synonyms. — Varicella. Swine-pox. Bastard-pox. Water- 
pox. False variola. 

History. — Chicken-pox was first described in France by Re- 
viere in 1660, and in England by Harvey in 1696. 

The name varicella, meaning little small-pox, came into use 
about 1770. 

Etiology. — The exact nature of the specific poison of chicken- 
pox is unknown. It may be communicated by inoculation, and 
attacks indifferently the vaccinated and the unvaccinated. It is 
commonly a disease of early life, and becomes markedly infre- 
quent after the seventh year. 

Clinical History. — After an incubation of from four to sev- 
enteen — usually eight — days, the attack sets in with slight chilli- 
ness, headache, languor, and occasionally vomiting, followed by 
more or less marked febrile movement. In twenty-four hours 
the eruption appears in the form of small, deep-red papular 
spots — varying in number from one dozen to several hundred — 
first upon the back and chest, and then upon the face and ex- 
tremities. On the second day the papules have become converted 
into vesicles. The vesicles are of small size, usually less than 

(371) 



372 LECTUKES ON FEVEES. 

one-fifth of an inch in diameter, oblong in shape, and contain a 
clear, transparent fluid which gives them a bright and glistening 
appearance. After twenty-four hours they become slightly tur- 
bid and lactescent — not puriform. On the fourth day desicca- 
tion begins, and is usually completed within two days. The 
scabs, which are thin, superficial, and of a light-brown color, fall 
off between the eighth and ninth days. A peculiar feature of 
chicken-pox is the appearance of the vesicles in successive crops. 
Not infrequently fifty or one hundred new spots will be observed 
to appear each night for four or five days. The eruption is gen- 
erally attended with considerable itching, and some slight con- 
stitutional disturbance. The temperature rarely exceeds 100° 
Fahr. 

Duration. — The duration of chicken-pox varies from four to 
seven days. 

Differential Diagnosis. — The disease with which chicken-pox 
is of tenest confounded, is varioloid. The following are the chief 
diagnostic points: 

The stage of invasion in varioloid is longer and the initiatory 
fever is much more severe than in chicken-pox. The chicken- 
pox rash appears on the second day, and in a few hours becomes 
vesicular, while the varioloid rash both appears and undergoes 
vesiculation later. In varioloid, as in ordinary small-pox, the 
eruption appears first on the face ; in chicken-pox it appears first 
on the body. The eruption comes out regularly in varioloid, and 
some of the vesicles are umbilicated. In chicken-pox it comes 
out irregularly and in successive crops, and presents no umbili- 
cation. The mildness of the constitutional symptoms is always 
marked in chicken-pox. 

Prognosis. — The prognosis is always favorable, unless com- 
plications arise. Recurrences of the disease have never been 
observed. 

Treatment. — Chicken-pox requires little treatment beyond 
attention to diet, and the careful avoidance of premature expo- 
sure to atmospheric changes. Rhus iox. is usually the only 
internal remedy required. If there is much febrile disturbance 
aconite may be of service. Apis mel. will prove useful if there 
is much itching with the eruption. Belladonna may be needed 
as an intercurrent remedy for headache and sore throat. Mer- 



CHART. 

CHAET XYL— Chicken Pox. 



373 



Nature: 


Epidemic. Contagious. 


Initial Symptoms : 


Chilliness. Headache. Lassitude. 


H 

W 

o 

Si 

>- 
13 

► 

a 

co 

25 

co 

a 

G 

C 
K 

Ul 
CD 

K 

C 

3 

nfl 

CO 


Age : 


Occurs mostly in children under seven years. 


Temperature : 


Rarely exceeds 100° Fahr. 


Nervous System : 


Slight nocturnal restlessness. 


Eruption: 


1st day. 


2nd day. 


3rd day. 


4th to 6th day. 


Papules. 


Oblong 

transparent 

vesicles. 


Lactescent 
vesicles. 


Desiccation. 

Brownish 

scabs. 


Cutaneous 
Surface: 


Heat and itching. 


Throat: 


Swelling of the lymphatic glands. 


Digestive Tract: 


Moderate thirst. Loss of appetite. 


Duration : 


Five to seven days. 


Prognosis : 


Always favorable. 


Recurrence : 


Chicken-pox occurs only once in a life-time. 


Incubation: 


From four to seventeen days. 



374 LECTURES ON FEVERS. 

curius or tartar emet will be called for, if any of the vesicles 
threaten to suppurate. 

The diet should be light and non-stimulating — milk is usually 
preferred. The irritation of the skin is best relieved by the 
application of oil or cosmoline. 

Miliary Fever. 

Though not, strictly speaking, a contagious disease, miliary 
fever is included in this class, by reason of its possessing many 
elements of contagion, and it is described here on account of its 
phenomenal prevalence in connection with measles and scarlet 
fever. 

Definition. — Miliary fever may be denned as an acute febrile 
affection, occurring in the form of short, circumscribed, local 
epidemics, characterized by profuse sweating attended with high 
fever, intense pain at the epigastrium, and a sense of suffocation, 
followed after the third or fourth day by a vesicular eruption, 
which in two or three days disappears by desquamation. Its 
average duration is from five to eight days. Relapses are com- 
mon. 

Synonyms. — Sweating sickness, Sudoral exanthema. Sudor 
anglicus. 

History. — The history of miliary fever dates back to the close 
of the fifteenth century, when it was first clearly described un- 
der the name of the "English sweating sickness." 

It appeared in England in 1486, shortly after the battle of 
Bosworth, and proved alarmingly fatal. 

It re-appeared in 1507 and again in 1518, when the epidemic 
was extremely violent. 

In 1529 it appeared in England for the fourth time, and soon 
extended to the continent, and overran the greater part of Europe. 
The last outbreak in England occurred in 1551. 

After an interval of over a century and a half (1718), miliary 
fever re-appeared in France, Italy, Germany, Austria and also 
Belgium. 

In 1802 an epidemic appeared at Itottingen, in Bavaria, and 
ran its course in ten days. 



CLINICAL HISTORY. 375 

It prevailed in Italy and Germany in 1837-39, and in Belgium 
in 1849. 

Miliary fever occurred in 1830 and 1855 simultaneously with 
epidemics of scarlet fever and measles. It occurred in connec- 
tion with cholera in 1849-54. 

Etiology. — The nature of the exciting cause of miliary fever 
remains as yet unknown. 

Epidemics are often limited to single places, or spread only 
over definite areas. They prevail mostly during the spring and 
summer months, and last on an average from seven to fourteen 
days; occasionally they continue two or three months. In some 
epidemics from one-fifth to one-tenth of the whole population is 
attacked b} T the disease. 

Like typhoid fever, miliary fever attacks the strong and the 
vigorous. It affects adult life mostly, and occurs oftener in 
women than in men. An attack affords no immunity from the 
disease, even during the same epidemic. 

Clinical History. — The clinical history embraces a descrip- 
tion of the stage of invasion, the sweating stage, and the stage 
of eruption and desquamation. 

The Stage of Invasion. — The prodromal stage or stage of in- 
vasion lasts from two to three days. The patient complains of 
excessive irritation of the skin, thirst, headache, and general 
lassitude. There is generally more or less febrile movement, 
and not infrequently a feeling of suffocation preceded by a sense 
of oppression at the epigastrium. 

The Sweating Stage. — In the evening or during the night of 
the second or third day, the second stage of the disease is ush- 
ered in, usually by rigors, seldom by a pronounced chill. A 
profuse and persistent sweat at once appears, accompanied by a 
prickling sensation in the skin, epigastric oppression, and palpi- 
tation of the heart with precordial pain. The temperature rises 
rapidly to 103° Fahr., and sometimes even to 105° Fahr. The 
pulse quickens to 130 or 140 beats per minute. The headache 
increases, and the palpitation of the heart becomes violent and 
tumultuous. The respirations become rapid, often irregular, 
and the sense of suffocation is extreme. The urine is generally 
turbid, scanty and high-colored, and there is great tenderness on 
pressure, in the epigastrium. After these symptoms have con° 



376 LECTUKES ON FEVERS. 

tinned unabated, or have displayed a tendency to irregular exa- 
cerbations or intermissions for three or four days, sometimes 
longer, the eruption appears, and the patient enters the third 
stage. 

The Stage of Eruption. — As the eruption appears, the symp- 
toms of the preceding stage rapidly abate. The rash consists of 
irregularly shaped spots which sometimes stud the skin so thickly 
as to resemble the eruption of scarlet fever. It appears first 
upon the neck and chest, and gradually extends to the back and 
extremities. After a few hours vesicles appear in the center of 
the spots, and rapidly increase in dimensions until they attain 
the size of a millet seed or a small pea. The vesicles contain at 
first a clear fluid which gradually becomes opaque and yellowish. 
After two or three days they burst or dry up, and form crusts 
which fall off in scales, within twenty-four hours. Convalescence 
is usually protracted in consequence of the great debility and 
emaciation. In some severe cases, during the sweating stage, a 
typhoid condition may be developed, or a sudden and fatal col- 
lapse may occur. 

Complications seldom occur; occasionally either bronchitis, 
pneumonia, sore throat or diarrhea accompany the disease. 

Duration. — The average duration of miliary fever is from five 
to eight days. Epidemics last from seven days to fihree months 
or longer. 

Morbid Anatomy. — Miliary fever presents no characteristic 
anatomical lesion. 

The blood is thin, bright-red during life, but dark-colored after 
death. Hyperemia of the lungs, liver, spleen and mucous mem- 
brane is generally present. Superficial ulcers are sometimes 
met with in the region of the ileo-csecal valve. The cutaneous 
eruption is caused by the hindrance to the escape of the sweat 
from the sweat glands. The imprisoned secretion emerges under 
the epidermis around the sweat duct, and as the scales become 
elevated a small, clear vesicle is formed. 

Differential Diagnosis.— The discrimination of miliary fever 
from other affections — more particularly typhoid fever, measles 
and dengue — having some points of resemblance to it, is, under 
ordinary circumstances, unattended with difficulty. The profuse 
sweating, the prickling of the skin, the intense oppression at the 



CHAKT. 

CHART XVIL— Miliary fever. 



377 



Nature: 


Prevails in limited epidemics. 


Stages: 


Invasion. 


Sweating. 


Eruption and desqua- 
mation. 


Duration : 


Two to three days. 


Three to four days. 


Three to four days. 


Cutaneous 
Surface : 


Excessive irritation. 


Profuse and persist- 
ent sweating. Hot 
skin. 


Eruption, first on 
neck and chest. Pap- 
ules and vesicles last 

two to three days. 


Nervous System . 


Headache. 


Intense headache. 


00 

>< 

2 o 
< % 
ft 
p| 

ll 

5 5 

E O 


Temperature : 


Slight fever. 


103* to 105°. 


Pulse : 


Accelerated. 


120 to 140. 


Heart: 


„ ,. , ,. .'Palpitation. Precor- 
Precordial distress. 1 ,. , 

dial pain. 

J 


Respiration: 


Suffocative feeling. j&g£tti?gS& 


Digestive Ti - act: 


Thirst. Oppression at Nausea- Oppression 
epigastrium. at epigastrium. 


Urine : 


m . ., , | High-colored. Sup- 
Turbid and scanty. ~ pressed. 


Profuse. 


Prognosis: 


Favorable in moderate cases. 


Convalescence: 


Often protracted. 


Relapsos: 


Relapses are of common occurrence. 



378 LECTUKES ON FEVERS, 

epigastrium, the precordial pain, the feeling of suffocation, and 
the peculiarity of the eruption, readily distinguish it from all 
other epidemic diseases. 

Prognosis. — The mortality varies in different epidemics; its 
average is from eight to ten per cent. The prognosis is generally 
favorable when the disease runs a regular course with only mod- 
erate severity. It is unfavorable when the temperature is high, 
the sweating profuse, and the sense of constriction intense; also 
when violent delirium, convulsions, coma or profuse hemorrhages 
supervene. 

Death most frequently occurs in the sweating stage, during 
the exacerbation which precedes the appearance of the eruption. 

Treatment. — Principal Kemeclies. — Bryonia is the main 
remedy during the first part of the disease. It is specially indi- 
cated if typhoid symptoms threaten. Aconite will be needed 
when there is great nervous excitement and marked febrile move- 
ment. Cactus will often relieve the palpitation and the sense of 
constriction with precordial pain. Arsenicum is called for if 
there is much anxiety and restlessness, with burning fever. Ja- 
borandi, sambucus or mercurius should be thought of when the 
sweating is very profuse. Ipecac if there is intense dyspnoea 
with a fainting sort of nausea. Apis when there is much itch- 
ing, or urinary suppression threatens. Sulphur during desicca- 
tion, and Cinchona during convalescence. 

Other remedies not infrequently of service are, amm. carb., 
ant. crud., bapt., bell., canst., cham., convallaria, digit., hepar 
sulph., hyos., lach., mez., nat. mur., phos., polyporus, puis., rhus 
tox., selen., sil., spig., sulph. acid, and verat. alb. 

The patient should be kept in bed and given a moderately nu- 
tritious diet. Frequent sponging of the surface with warm 
water is highly beneficial. Stimulation may be needed in severe 
cases. 



LECTUBE XXV. 

Measles. 

Measles is the most prevalent of all the fevers. 

Definition. — It may be defined as an acute, epidemic conta- 
gious disease, lasting about seven days, occurring mostly in 
early life, characterized by an eruption of red spots resembling- 
flea-bites, which coalesce into crescents, accompanied by catarrhal 
symptoms, more or less fever, and general constitutional dis- 
turbance. It is generally unattended with danger, but is espe- 
cially liable to be followed by sequels. It rarely occurs a second 
time in the same individual. The period of incubation averages 
from nine to twelve days. 

Synonyms. — Rubeola. Morbilli. Eougeole. Masern. 

History. — Measles invaded the world about the same time as 
small-pox. It is supposed to have started on the shores of the 
Reel Sea during the fifth or six century. 

It was described by the Arabian physician Rhazes in the early 
part of the tenth century. The term rubeola was introduced 
somewhat later by the Latin translators of Hali Abbas, who de- 
scribed it under the name Hasba or Alhasbet. 

Rhazes and Avicenna taught that small-pox, measles and scar- 
let fever were the same disease. 

Measles was first distinguished from small pox by the Arabian 
physicians of the twelfth century. Morton viewed measles and 
scarlet fever as products of the same miasm, and believed that 
they stood in the same relation as distinct and confluent small-pox. 

In 1670 Sydenham carefully restricted the term morbilli — 
hitherto used in describing scarlet fever and measles as one dis- 

(379) 



380 LECTURES ON FEVERS. 

ease — to measles, and clearly distinguished the latter from 
small-pox. Measles and scarlet fever, however, continued to be 
confounded until about one hundred years ago. 

The first records of true epidemics of measles were furnished 
by Forest in 1563. 

Etiology. — 1. The Predisposing Causes. — Measles appears at 
all seasons of the year, arid affects every latitude. Epidemics 
are more severe during the winter than during the summer 
months. 

Meteorological conditions exert little influence upon measles. 
Low and damp situations, however, are supposed to favor its 
prevalence and encourage the development of complications and 
sequels. 

Age exerts considerable influence as a predisposing cause. It 
is for the most part an affection of early life, being most fre- 
quent between the ages of two and five years. After fifteen 
years the liability to the contagion diminishes but never entirely 
disappears among those who are not protected by previous 
attack. 

Sex exerts little influence. The statistics of measles show 
that males are more frequently attacked than females. 

Race and nationality have but little influence. The suscepti- 
bility to the contagion is almost universal. Savages have some- 
times suffered greatly from it. 

2. The Exciting Cause. — Measles is caused by a specific poison, 
the exact nature of which is still unknown. Klebs and Keating 
describe it as a micrococcus. It is found in the mucous secre- 
tions and in the blood of individuals suffering from it, and may 
be conveyed by inoculation. It may be carried in the clothing 
and in fluids — which act as f omites — from one place to another. 
Measles, therefore, is in a certain sense a portable disease. It 
is contagious in all its stages, and its poison is more tenacious 
than that of either small-pox or scarlet fever. As a rule, a per- 
son unprotected is more certain to take measles than is an un- 
protected individual to contract small-pox or scarlet fever under 
similar circumstances of exposure. The period of incubation 
varies from five to twenty days — usually it extends from nine to 
twelve days. 



CLINICAL HISTOEY. 08I 

Clinical History. — The clinical history embraces a description 
of the premonitory, eruptive and desquamative stages. 

Premonitory Stage. — At the close of the period of incubation 
— a period without fever, and free from local symptoms — the 
disease sets in with symptoms resembling those of a severe cold, 
or rather an attack of influenza. The patient is languid and 
chilly, and complains of frontal headache, and pains in the back 
and limbs. There is coryza with frequent sneezing, and a con- 
stant irritating, watery discharge from the nostrils. Febrile 
movement, accompanied by irregular chilly sensations and shiv- 
ering soon follows, and the temperature may rise to 102° Fahr. 
or 104° Fahr. The eyes are injected and watery, and the tears 
excoriate the face. There is great drowsiness with wandering 
and screaming at night. The tongue is usually furred, the ap- 
petite is either impaired or lost, and, in some cases, nausea and 
vomiting occur. The bowels are either natural or there may be 
slight constipation or diarrhea. There is slight soreness of the 
throat with a dry, hoarse, laryngeal cough, and slight dyspnoea. 
A rose-colored, punctate redness of the tonsils, roof of the mouth 
and palate is frequently observed twenty-four hours before the 
eruption appears. A red papule is often observed near the free 
border of the uvula several days before the rash appears upon 
the skin. 

This stage lasts from three to five — usually four — days . Upon 
its conclusion the eruption appears, usually with an increase of 
the fever, which had in a great measure abated, and an eleva- 
tion of the temperature to 103° Fahr., or even 106° Fahr. 

The Eruptive Stage. — The eruption appears usually first upon 
the temples and forehead, and thence extends in about thirty 
hours over the neck, trunk and extremities, appearing latest upon 
the dorsum of the hand. At first it presents the appearance of 
minute, round, bright rose or deep red spots, not unlike flea-bites, 
varying between one-twentieth and one-fourth of an inch in di- 
ameter. Scanty at the beginning, these flat-topped papules — 
for such they rapidly become — soon become numerous, especially 
on the face, and are often crowded together in patches of a cres- 
centic or semi-lunar shape, w T ith normal colored skin between 
them. When pressed upon, their color disappears, to return 
rapidly from the center to the periphery, when the pressure is 
removed. After the' eruption has existed for two or three days, 



382 LECTURES ON FEVERS, 

it begins to fade, first from the face, and successively from the 
neck, chest and extremities. 

As the rash makes its appearance, the skin becomes hot and 
swollen, especially on the face, and is attended with more or less 
itching and burning. The coryza increases, the fever rises, and 
there is a general exacerbation of the symptoms. The pulse 
ranges from 100 to 140 or even 160, and the temperature may 
run up to 104° Fahr. or 106° Fahr. It remains at 102° Fahr. or 
103° Fahr. in ordinary cases. The respirations are short and 
hurried. The cough continues and is loud, hoarse and frequent. 
It has been termed the " iron cough " of measles. Bronchial rales 
are frequently seen upon the physical exploration of the chest. 
The irritation of the eyes continues, and not infrequently there 
is conjunctivitis. The tongue is covered with a thick, creamy 
fur in the center, but is clean and red at the tip and edges . The 
sore throat continues, and there is marked redness of the tonsils, 
pharynx and soft palate. The urine is turbid and scanty, and 
contains urates. The duration of this stage is from three to 
four days. 

The Stage of Desquamation. — After the eruption has reached 
its height — usually on the second day — the disease remains 
nearly stationary during the balance of the eruptive stage, and 
then gradually abates. The rash now begins to fade, the tem- 
perature declines two or three degrees, the. pulse lessens in fre- 
quency, and the catarrhal symptoms subside. The eruption, as 
a rule, begins to decline upon any part, about thirty-six hour 
from the time of its first appearance upon that part. It steadily 
disappears from above downwards in the order in which it first 
appeared; not infrequently it will have faded from the face and 
neck, while it is still more or less prominent upon the extremi- 
ties. The cuticle desquamates in the form of furfuraceous or 
branny scales in a considerable number of the cases, leaving 
yellowish-brown pigmentations of the surface, where the ele- 
ments of the eruption have existed. These pigmentations or 
stains remain a variable length of time, and are gradually re- 
moved by absorption. Desquamation is usually accomplished 
in from three days to one week, and is often scarcely noticeable. 
Coincident with the disappearance of the eruption, the febrile 
movement ceases, and the patient becomes convalescent. 



IRREGULAR TYPES. 383 

Duration. — The duration of the disease varies from twelve 
to sixteen days. 

Irregular Types. — Anomalous cases of measles not infre- 
quently occur during the course of epidemics. They are de- 
pendent partly upon the intensity of the poison, partly upon the 
degree of physical vigor, and partly upon the hygienic surround- 
ings. 

At times the eruption is irregular and fitful. In mild cases it 
may fade in a single night, and no evil consequences result from 
the disappearance. Occasionally the papules are small in size, 
few in number, and light colored. The order of their appearance 
may be partially reversed, so that instead of cropping out first 
upon the face and then upon the trunk, they may show them- 
selves first on the trunk, and afterwards on the face. Sometimes 
the stains after desiccation assume a livid or purplish hue, unat- 
tended by malignant or dangerous symptoms. An irregular 
variety occasionally prevails epidemically, among the poorly 
nourished and badly hygiened, characterized by a tendency to 
ulceration of the mucous surfaces. Cases formerly described as 
presenting catarrhal and febrile symptoms without the eruption 
— rubeola si)ie eruptione — were, to say the least, very doubtful 
cases of the disease, while those alluded to as measles without 
catarrhal symptoms — rubeola sine catarrho — were in all proba- 
bility, simply cases of roseola. 

Malignant Measles. — This irregular type of the disease gen- 
erally prevails epidemically; occasionally it occurs sporadically. 
It is commonly known as " black measles,'" and may appear in 
either of two forms: 

1. An irregular form in which there is a very high range of 
temperature from the beginning of the attack. There is usually 
great restlessness, dyspnoea, and dryness of the tongue. The 
eruption, which at first may be bright-red, early assumes a dark- 
claret hue. The dark color of the eruption is due to the changes 
in the blood consequent upon the high temperature. 

2, A form, called by some hemorrhagic measles, in which the 
eruption is largely composed of petechial spots scattered over 
the surface. A few days after the onset of the fever and the 
appearance of the eruption as in the ordinary form of the dis- 
ease, the eruption assumes a dark color, and the symptoms take 



384 LECTUEES ON FEVEES. 

on a typhoid character. The tongue becomes dry and glazed in 
the center, sordes collect upon the teeth, and there may be vom- 
iting and diarrhea. The peculiarities of this form are dependent 
upon a hemorrhagic diathesis. 

In either of these irregular types the patient may die of 
exhaustion, or of congestion of the internal organs, or from 
hemorrhages. 

Complications and Sequels. — The most important complica- 
tions of measles are seated in the respiratory system. 

Capillary bronchitis, following the ordinary bronchial catarrh 
of the disease, is most apt to occur in young children. It may 
develop at any stage, and is always of serious import. The 
great danger when the bronchitis becomes diffuse and extends 
into the finer tubes, is that atelectasis and secondary lobular 
pneumonia will ensue, and destroy the life of the patient by cut- 
ting off extensive areas of breathing surface. Capillary bron- 
chitis is attended with increasing dyspnoea, lividity of the face 
and extremities, and great prostration. Crepitant and sub-crep- 
itant rales at the lower portions of the posterior dorsal regions, 
without dullness at first, and with increased resonance later, usu- 
ally attend its appearance. In children under three years of age 
capillary bronchitis generally proves fatal. 

Pneumonia may occur at any time during the course of the 
disease, but is not liable to follow after the eruptive stage. It 
is always attended with danger, and in very young Children is 
likely to prove fatal. 

Catarrhal laryngitis is a not uncommon complication. It is 
often accompanied by pharyngitis and is characterized by sore- 
ness of the larynx, and a loud, shrill, ringing cough. 

Acute miliary tuberculosis not infrequently occurs as a sequel 
of measles in adults. 

Colitis may occur as a complication during the initial stage or 
at the beginning or close of the eruptive stage. 

Secondary meningitis may occur as a complication during the 
decline of the rash. 

Conjunctivitis, otorrhcea and suppuration of the cervical glands 
are common sequels in patients who have a strumous diathesis. 



CHART. 

CHART XVIII.— Measles. 



385 



Nature: 


Epidemic. Contagious. Portable. 


Stages: 


Premonitory. 


Eruptive. 


Desquamative 


Duration : 


Four days. 


Four to six days. 


Two to six 
days. 


Chest: 


Bronchial catarrh. 


"Iron cough" 
Hoarseness. 


Cough grad'lly 
disappears. 


Skin: 


Hot and dry 


Papular crescents. First 
on lace. Itching. 


Branny scales. 
Itching. 


Throat : 


Sore throat. Reddish 
puncta . 


Pharyngitis. Reddish 
puncta. 


' w 

d 

rjtf 

5 

H 

O 
H 

O 

H 
O 

s 


Eyes: 


Watery. Injected. 


Conjunctivitis . 


Nose: 


Coryza. Sneezing*. 


> 
O 

o 

> 
< 
> 

O 



«j 

O 
en 


Head: 


Drowsiness. Frontal 
headache. 


Urine: 


Scanty. High-colored. 


Tongue : 


Moist. White. 


Moist. Clean 


Stomach: 


Thirst. Anorexia. 


Appetite re- 
turns. 


Bowels : 


Constipation. 


Constipation or 
diarrhea. 


Normal. 


Pulse: 


100 to 120. 


100 to 120 or 160. 


Falls to nor- 
mal. 


Temperature : 


102° to 104° first day, 
Declines 2nd and 3rd day. 


103° to 107° 


Rapid defer- 
vescence. 


Complications: 


Bronchitis. Pneumonia. Conjunctivitis. Colitis. 


Incubation: 


Ten to fourteen days. 



386 LECTURES ON FEVERS. 



ANALYSIS OF CHART. 



The Nervous System.— Chilly sensations and shivering usu- 
ally usher in the attack. 

Headache is a prominent and early symptom. Oppressive 
frontal pains are scarcely ever absent. They extend across the 
brow and to the root of the nose. 

Drowsiness often exists during the premonitory stage, after 
which the patient is usually restless and sleepless. 

Convulsions sometimes occur at the onset of the disease, in 
children. 

Mild delirium is not uncommon. 

The Respiratory Tract. — A more or less extensive hypere- 
mia of the mucous membrane of the respiratory tract is inva- 
riably present. 

There is coryza with general catarrhal symptoms. The eyes 
are injected and watery, and the eyelids are swollen and reddened. 
There is abundant lachrymation. Conjunctivitis not infrequently 
occurs during the eruptive stage. Sneezing is frequent, and the 
discharge from the nose is abundant. Epistaxis sometimes 
occurs. Sore throat with tickling sensations and difficulty in 
swallowing is often complained of, and is due to inflammation of 
the pharynx and neighboring parts. Occasionally in the pre- 
monitory stage, the roof of the mouth, soft palate and uvula, 
exhibit minute rose-colored puncta. Hoarseness is common. 
All the catarrhal symptoms are, as a rule, increased in intensity 
-during the development of the eruption. The most common 
period for the occurrence of pulmonary complications is the 
initial stage. 

Cough is a prominent symptom. It is apt to be frequent and 
distressing, and is harsh, hollow and brassy. Not infrequently 
it is worse towards evening and at night. The respirations may 
be hurried and short. Sonorous and sibilant or mucous and 
sub-crepitant rales are frequently detected upon both sides of 
the chest in the course of the attack. 

The Temperature. — The initial or prodromic fever in mea- 
sles is usually complete in from twelve to twenty-four hours, 
during which time the temperature rapidly rises to 102.5° Fahr. 
or 104° Fahr. The height attained during this stage is an index 
of future elevations, which tend to exceed the initial rise by 



ANALYSIS OF CHART. 387 

from 1° Fahr. to 2° Falir. The initial rise is generally followed 
by a rapid descent the next night, so that on the following morn- 
ing the temperature seldom exceeds 100° Fahr., and may be 
normal. The fever of eruption begins with renewed rise of 
temperature, and unlike the initial fever, has only temporary 
remissions until the rash is fully developed. In normal cases 
the maximal temperature is reached in from twenty-four to 
thirty-six hours after the beginning of the eruptive stage, and is 
contemporaneous with the fullness of the eruption. In others 
it may precede the acme of eruption, on account of some 
complication. When the temperature is at its maximum, the 
thermometer in the axilla may register 106° Fahr. and even 
higher. Should the acme begin in the evening, the next morn- 
ing remission will be either slight or missing. 

Defervescence begins usually in the night, as the eruption 
begins to decline, and runs a rapid course, the temperature 
reaching the normal on the second morning. At times it is pro- 
tracted by bronchitis and other complications. Sub-normal 
temperatures are occasionally observed in the first days of con- 
valescence. 

The Pulse. — The pulse ranges from 100 to 120 beats per min- 
ute, and in young children may reach 160 beats. As the eruption 
passes its maximum of development the pulse lessens in fre- 
quency, and rapidly returns to the normal, unless quickened by 
complications. 

Tlie Cutaneous Surface. — The skin is usually hot and dry, 
and during the eruptive stage there is more or less swelling of 
the surface with itching and burning. 

The eruption of measles appears, as a rule, on the fourth day. 
Exceptionally it is met with as early as the second day, or not 
discovered until as late as the fifth or seventh day. It consists 
of slightly elevated isolated spots of a bright or deep red color, 
varying from half a line to three lines in diameter. It is first 
seen upon the face — temples and forehead — and gradually spreads 
over the trunk and extremities. It requires, in most instances, 
from thirty-six to forty-eight hours for its full development. Its 
average duration is from four to six days. 

The course of the measles eruption, is as follows: at first the 
lesion consists of little, fine, red dots, not unlike flea-bites, which 



388 LECTURES ON FEVERS. 

soon develop into true papules with broad, flat summits. After 
a short time these papules become numerous, and are crowded 
together in irregularly crescentic patches. The skin between the 
patches usually presents a natural appearance, although in se- 
vere cases when the patches are numerous, the whole cutaneous 
surface may assume a deep red tint. The eruption reaches its 
acme on the second day, and remains stationary about one and a 
half or two days, and then fades, wholly disappearing about the 
sixth day after its appearance. The time which elapses between 
the starting point of the period of incubation — the moment of 
contagion — to the maximum of eruption, averages about fifteen 
days. As the eruption disappears it loses its bright red color 
and becomes a yellowish-red, which gradually fades until noth- 
ing but a staining of the surface is left. 

Desquamation follows the disappearance of the eruption. It 
is generally fine and bran-like, and proceeds from above down- 
wards. 

The Digestive System. — The tongue is generally moist, white 
and somewhat furred. During the eruptive stage it is usually 
coated in the middle, but red at the tip and edges. A dry tongue 
with a temperature of 106° Fahr. or 107° Fahr. on the first day 
of the eruptive stage, is indicative of malignant or black measles. 

The appetite is, as a rule, impaired up to the stage of decline 
of the eruption. Thirst is commonly present. Nausea and 
vomiting occur in the early stages in a small proportion of cases. 

Constipation is of frequent occurrence. Slight diarrhea, last- 
ing from one to three days, is often present during the eruptive 
stage. 

Colitis with inflammation and tumefaction of the solitary 
glands, occurring during the stage of eruption, is indicative of 
danger, especially in young children. 

The Urine. — The urine is usually diminished. It often shows 
but little change, but is commonly, as in other fevers, concen- 
trated and high colored. It is of a dark yellow color in the 
eruptive stage; not rarely, it contains traces of albumen. 

Morbid Anatomy. — Measles presents no characteristic ana- 
tomical lesions, other than the changes in the skin and mucous 
membranes. 



MORBID ANATOMY. 389 

The blood is usually thin and dark colored, and is deficient in 
fibrin and red corpuscles. Klebs found the micrococci of mea- 
sles in the blood taken from the hearts of infant cadavers. Drs. 
Braidwood and Vacher found highly ref ractile spherical bodies in 
the breath of measle patients, and similar bodies, together with 
rod-shaped fusiform and ovoid bodies in the corium, lungs and 
liver. Dr. Keating found micrococci not only in the liquor san- 
guinis, but also in the substance of the white corpuscles in the 
blood in malignant cases. 

The mucous membrane of the eyelids, nose, pharynx, larynx, 
and larger bronchi is more or less intensely congested. It pre- 
sents a reddish or slightly blackish appearance, and exhibits the 
ordinary anatomical changes of acute catarrh. The catarrh 
which may be considered pathognomonic, is usually most se- 
vere immediately preceding and during the early period of 
eruption. Micrococci and bacteriform elements have been ob- 
served in the nasal mucus and in the catarrhal secretions of the 
respiratory tract. 

Evidences of capillary bronchitis and catarrhal pneumonia 
are, not infrequently, found after death. 

The eruption of measles during life, is papular. In its early 
stages, slight hyperemia at the orifice of a hair-follicle, with 
slight swelling from effusion of plasma is observed. Around the 
hypersemic papule a roseolous patch, due to hyperemia of the 
papillary body, soon appears. In form the patches are crescent- 
shaped, their outlines are sharply defined, and their color is 
bright red, sometimes shading off into blue. Not infrequently 
each patch contains several papules, and then the early papule 
usually occupies the place of a hair follicle. As soon as the 
patches have reached their maximum of development, their color 
begins to fade. The pale-brown stains which remain after the 
fading of the rash, are due to changes in the escaped red corpus- 
cles, and may be visible two weeks. No traces of the eruption 
can be found on the dead body. 

Congestion and inflammation of the colon with inflammation 
and tumefaction of the solitary glands sometimes occur. 

The spleen is somewhat enlarged, and there is more or less 
extreme congestion of the internal organs. 



LECTUEE XXVI. 

Measles ( Continued. ) 

Differential Diagnosis.— The direct diagnosis o£ measles 
must remain more or less doubtful, until the eruption appears. 
Of diagnostic importance during the epidemic prevalence of the 
disease, are, the suffused eye, the swollen eyelids, the coryza and 
sneezing, and the frequent, hoarse, scraping cough with fever, 
thirst, pain in the frontal sinuses, and the appearance of a punc- 
tated eruption on the hard and soft palate fifteen or twenty hours, 
before the development of the cutaneous rash. Ordinarily, after 
the eruption has come out fully, the diagnosis is not difficult. 

The diseases for which at first sight it may be mistaken, are, 
influenza, scarlet fever, german measles, small-pox, roseola, ty- 
phus fever and the erythematous syphilide. 

The main points of contrast between measles, scarlet fever,, 
german measles and small-pox, are arranged in a tabular form 
upon pages 402 and 422. 

Roseola and measles present some points of resemblance, the 
most important of which relate to the character of the rash. 
The eruption in measles appears on the fourth day, and is par- 
tially confluent. It is preceded and attended by catarrhal symp- 
toms, and by fever which runs a characteristic course. The 
eruption of roseola appears on the first day, presents no catarrhal 
symptoms, and is attended with but slight fever. Measles is 
contagious; roseola is non-contagious. 

The differential diagnosis between measles and typhus fever 
may be found on page 291. 

Measles may be differentiated from the erythematous syphilide 
by the glandular changes which characterize the latter disease.. 
(390) 



TREATMENT. 391 

Prognosis. — The prognosis in simple, uncomplicated cases of 
measles, is always favorable. In malignant cases it is of neces- 
sity grave. Pregnancy in women, and dentition in children, 
render it unfavorable. 

The conditions for a favorable prognosis are : when the disease 
is primary, when the eruption occurs on the fourth day and runs 
a regular course, when the fever is moderate, and when the 
cough and other symptoms diminish with the fever. 

The conditions for an unfavorable prognosis are: when the 
disease pursues an irregular course, when the symptoms of the 
premonitory stage are violent and the temperature reaches 105° 
Fahr. or 106° Fahr., when the tongue becomes dry, when the 
eruption becomes livid, when the fever does not disappear with 
the eruption, when profuse hemorrhages from the mucous sur- 
faces occur, when the cough, dyspnoea or diarrhea continue, or 
when the disease occurs in a patient suffering from some chronic 
disease. 

The occurrence of any of the more serious complications, such 
as capillary bronchitis, catarrhal pneumonia, colitis, etc., always 
renders the prognosis bad. 

The mortality of measles is generally slight, except during 
malignant epidemics, and when occurring in badly-nourished, 
cachectic and scrofulous subjects. It is much greater in adults 
than in children. When death occurs, it is mostly during or 
after the second week of the disease. 

Treatment. — Prophylaxis. — Isolation is the most effective 
preventive measure. It should be instituted as early as possible, 
and continued for some time after the eruption has disappeared. 
At least one week should elapse after the fall of the temperature 
to the normal, or after the entire disappearance of the rash, be- 
fore the patient should see any one other than the attendants. 
The contagiousness is somewhat diminished by frequent bath- 
ing, and by night and morning inunctions. 

Pulsatilla, though generally recommended, is of doubtful effi- 
cacy as a prophylactic. 

Principal Remedies. — Aconite is adapted to the febrile and 
catarrhal symptoms of the premonitory stage. It mitigates the 
fever, and allays the nocturnal cough and feverish restlessness. 
Gelsemium is indicated when the eruption is slow in appearing^ 



392 LECTUEES ON FEVERS. 

when there is drowsiness with high fever, and when there is a 
tendency to convulsions. Veratrum viride is needed if there is 
much cerebral or nervous irritation with tendency to convulsions, 
or if congestion of the lungs threatens. Belladonna is of use 
early in the disease, if there is much irritation of the fauces or 
larynx, or a dry spasmodic cough ; also, if there is a tendency to 
delirium. 

Euphrasia is indicated when the catarrhal symptoms are 
chiefly nasal and conjunctival, when the eyes are very sore, and 
when there is profuse, fluent coryza. Dry cough is a character- 
istic. Kali hyd. may be useful in the premonitory stage, when- 
the catarrhal symptoms are marked. It is preferable to euphra- 
sia when chest symptoms are prominent. Pulsatilla is indicated 
when there is dry coryza, and when there is marked nervous 
irritation in the early days of the eruptive stage. It is the chief 
remedy when gastric symptoms are troublesome. Bryonia is 
needed when the eruption recedes or becomes livid, and typhoid 
symptoms appear. It should be given early, when there is in- 
flammatory irritation of the bronchi. Kali bich. is suitable 
when there is hoarse scraping in the chest, or when simple bron 
chitis supervenes. Phosphorus is called for when pneumonic 
complications exist, especially when hoarseness, dry, hacking, 
hollow cough with raw scraping feeling in the chest, and muco- 
sanguinolent expectoration are present. Tartar emet. is useful 
for either the bronchitis or the pneumonia, when there is oppres- 
sion of the chest with difficult, rattling breathing. Ipecac may 
be given for retching and vomiting, and for teasing cough from 
tickling in the throat with dyspnoea. Red iodide of mercury for 
glandular swellings and for obstinate cough during convalescence. 

Gelsemium, bryonia, cuprum acet., opium, ipecac and ammo- 
nium carb. are the principal remedies for suppression or retro- 
cession of the eruption. Arsenicum is the main remedy in 
malignant cases, when the eruption is of a dusky hue and there 
is great depression with blueness and coldness of the surface. 
Secede is useful in low putrid states, and when gangrene threatens. 

As intercurrents : coffea may be needed for wakefulness. He- 
par sulph. for wheezing, or slightly loose, croupy night cough. 
Spongia for dry, croupy cough with burning in the larynx and 
trachea. Hyoscyamus for short, dry, titillating night cough. 
Eupatorium perf. for loose, nocturnal cough during convales- 



LEADING INDICATIONS. 393 

'cence. Mercurius cor. for dysenteric stools. Arsenicum or verat. 
alb. for diarrhea. 

Silicea, mercurius and hepar are most important remedies for- 
otorrhcea. Arsenicum, mercurius cor. and hepar for ophthalmia. 
Sulphur and mercurius during the decline of the eruption. An- 
timonium crudum during convalescence, when the appetite does 
not return and the tongue remains thickly coated. Cinchona and 
phosphoric acid if there is much debility during convalescence. 

Leading Indications. — Aconite. — High febrile excitement 
with full, hard, quick pulse. Restless sleep with jerking and 
starting. Distressing pressure at the root of the nose (mere). 
Grating of the teeth (hell). Short, dry, racking cough from 
tickling in the larynx, with or without oppression. Stitches in 
the chest (bry.). Cory za with sneezing (sang.). Pain in the 
stomach and bowels with vomiting and diarrhea. 

Ammonium carb. — Fluent coryza with stoppage of the nose. 
Burning water runs from the nose (mere. cor. ). Roughness and 
scraping in the throat (caust). Cough worse after midnight. 
Dyspnoea from retrocession of eruption. Child starts from sleep, 
cannot get his breath. Adynamic state. 

Antimonium cruel. — Child is delirious and drowsy with hot, 
red face. Redness and inflammation of the eyelids (mere, sulph.). 
Tongue coated thick, white ( bry., mere. ). Gastric derangements, 
(pids.). Pains in the ears. 

Apis mel. — Confluent eruption and oedematous swelling of 
the skin (ars.). Eyelids swollen, red and oedematous. In- 
tensely deep, red rash (bell.). Catarrh of the bowels with 
diarrhea. Prostration, muttering and delirium. 

Arsenicum. — Great anxiety and restlessness. Extreme debil- 
ity with dyspnoea on lying down. Frequent sneezing with pro- 
fuse, watery discharge from the nose, corroding the lips and 
making the upper lip sore (arum, mere. cor.). Profuse lachry- 
mation and burning in the eyes (aconite). Great thirst with 
chilliness after drinking. Pale, earthy color of the face. Cough 
with frothy, tough expectoration. When coughing a pain ex- 
tends from the lumbar region down into the thighs. Diarrhea; 
the evacuations excoriate the anus (mere). Petechise. In ady- 
namic cases. 



394 LECTUKES ON EEVEKS. 

Belladonna." — Constant drowsy sleep, or drowsiness with ina- 
bility to go to sleep. Starting and jumping during sleep with 
flushed face and red eyes. Dryness of the nose with dull, fron- 
tal headache. Frequent sneezing, sore throat and hoarseness. 
Dry, spasmodic or hollow, hoarse cough, worse at night (dros.). 
Over-excitability of all the senses ( coffea ) . Convulsions. 

Bryonia. — Dry, painful cough with roughness and dryness of 
the larynx. Great dyspnoea and quick breathing. Congestion 
of the chest with shooting and stitching, increased by deep 
breathing (phos.), Urination when coughing (cina). Rheu- 
matic pains in all the limbs. Retrocession of eruption with 
prostration and fever. Constipation. Sitting up in bed causes 
nausea and f aintness. 

Camphor. — Great anxiety and restlessness (ars.). Suppres- 
sion of eruption (bry., cuprum). Pale, anxious face. Bluish- 
purple color of the skin. Suffocative dyspnoea. Weak, scarcely 
perceptible pulse. Sudden and great prostration with spasmodic 
stiffness of the body. In cases assuming a malignant form. 
Painful and difficult urination occurring as a sequel (apis). 

Carbo. veg. — Pressive headache in the forehead just over the* 
eyes. Painful stitches through the head when coughing (bry.). 
Itching on the margin of the lids (sulph.). Violent, almost 
constant eructations (puis.). Persistent hoarseness (caust > 
plios.). 

Cuprum acet. — Nausea and vomiting, relieved by drinking 
cold water (bry. ). Sudden retrocession of eruption (amm. carb., 
bry.). Epileptiform convulsions. Spasmodic attacks of dysp- 
noea. Blueness of the face and lips (lack.). 

Brosera. — Paroxysmal cough after measles. Constrictive 
pain in both hypochondria which impedes coughing. Must sup- 
port the sides with the hands when coughing (eupai perf.). 
Hoarseness with oppression of the chest, worse from talking 
( caust. , phos. ) . Barking cough ( rumex ) . 

Eupatorium perf. — Coryza with sneezing, hoarseness, and 
aching pains all over as if bruised (am.). Headache with pain 
and soreness in the eyeballs; photophobia. Cough with retching 
(dros.). Hacking cough in the evening with soreness in the 
chest (caust); must support the chest with the hands when 
coughing (dros.). 



LEADING INDICATIONS. 395 

.Euphrasia.— Dull frontal headache (mere, puis.). Profuse, 
fluent, bland' coryza with scalding tears (opp. ars.)) aversion to 
light. Burning in the eyes with lachrymation. Dry, tickling, 
laryngeal cough during the day, relieved by eating and drinking. 

Gelsemium.— Chilliness along the spine. Sneezing with ting- 
ling, especially in the left nostril (graph.). Stoppage of the 
right nostril; irritating discharge from the left nostril with scald- 
ing sensation. Bruised feeling in the eyes (bry.). Shooting 
pains in the ears when swallowing. Sore throat with collection 
of mucus. Bawness of the chest with hard, painful cough. 
Great drowsiness during the fever. Betroceding eruption with 
livid spots, and cerebral symptoms. 

Hepar sulph. — Intense headache above the nose (mere). 
Darting pains in the ears with cracking noises when blowing the 
nose. Feeling as of sand in the eyes (sulph.). Boughness and 
scraping sensations in the throat (mix). Cough with constant 
hoarseness. Cough caused by uncovering any part of the body 
(7~hus). 

Ipecacuanha. — Coryza with stoppage of the nose. Tardy 
appearance of the eruption with oppression of the chest (puis.). 
Incessant, dry, titillating cough, with rattling of mucus. Much 
nausea and vomiting. In delicate children. 

Kali l)ich. — Frontal headache, usually over one eye (sang.). 
Lateral headache in small spots. Fluent, acrid coryza, excori- 
ating the nose and lips (arum, mere. cor,). Flowing of water 
from the eyes, with burning when opening them. Stitches in 
the left ear, extending into the neck and head, with swelling of 
the glands (mere,). Battling cough with viscid, stringy expec- 
toration. Morning hoarseness (causi., hepar). 

Kali hyd. — Violent sneezing, and running of acrid water from 
the nostrils. Sensation of fullness and tightness at the root of 
the nose, with throbbing and burning pains in the nasal and 
frontal bones (kali bich.). Burning in the eyes with profuse 
lachrymation. Bawness in the larynx; stitches from the sternum 
to the back. Short, dry, hacking cough with whitish and green- 
ish expectoration. 

Lachesis. — Fluent coryza and lachrymation (ars., kali hyd.). 
Throat sore, especially when touched (apis). Pain in the left 



396 LECTUEES ON FEVEES, 

ear when swallowing. Dry, spasmodic, nightly cough, aggra- 
vated by sleep. The eruption appears slowly, or turns black or 
bluish. Sordes on the teeth. Inability to protrude the tongue. 

Mercurius. — Frequent sneezing with profuse, fluent, corrosive 
coryza (arum, kali hyd.). Burning in the eyes and profuse flow 
of tears. Inflamed and ulcerated tonsils (bell., hepar). Stitches 
in the right side of the chest when sneezing or coughing (bry.). 
Constipation, or mucus, bilious diarrhea. Slimy stools, streaked 
with blood. Much sneezing without relief. 

Nux vom. — Coryza with sneezing, worse in the morning and 
after eating. Great debility with over-sensitiveness of all the 
•senses (cinch.). Drowsiness in the day-time and after eating. 
Dry, racking cough with headache as if the skull would burst. 

Phosphor us. — Throbbing headache; headache over the left 
eye ( aco. ) ; worse in the evening. Frequent sneezing with alter- 
nately fluent and dry coryza. Difficult hearing, especially of the 
human voice. Hoarseness and roughness of the voice (canst, 
hepar). Dry, tickling cough with tightness across the chest, 
relieved by pressure upon the external walls. Cough worse be- 
fore midnight, and from reading, laughing or speaking; better 
after sleeping (opp. lach.). Mucous rales in both lungs, espe- 
cially the lower lobes (ipecac, tartar emet). Painless, watery 
diarrhea. Typhoid symptoms with loss of consciousness. 

Pulsatilla. — Fuent or dry coryza with frequent sneezing, and 
loss of taste and smell (sidph.). Inflammation of the eyes with 
profuse lachrymation (euph.). Darting, tearing, pulsating pains 
in the right ear at night (mere. ). Roaring in the ears, as if from 
the rushing of waters. Dry cough at night or in the evening, 
especially after lying down (hyos). Loose cough with vomiting 
of mucus, and nightly diarrhea. Gastric disturbances (nux). 
Chronic, loose cough occurring as a sequel. 

Rlius tox. — Frequent, violent, spasmodic sneezing. Hot, 
acrid discharge from the nose. Aching, pressing pains in the 
eyes (canst ) ; oedema of the lids (apis). Short, dry cough from 
tickling in the bronchi (rumex). Putting the hands out of bed 
brings on the cough (hepar). Great restlessness, must change 
position often (opp. bry:). Typhoid symptoms. 

Sticta. — Incessant sneezing, with a feeling of fullness in the 
right side of the forehead down to the root of the nose, with 






HYGIENIC AND DIETETIC TREATMENT. 397' 

tingling in the right nostril. Splitting frontal headache. Dry, 
racking cough in the evening and at night, excited by inspiration. 
Cough from tickling in the right side of the trachea, with op- 
pression of the chest. Conjunctivitis with profuse but mild 
discharge. 

Stramonium. — Frightful visions before the outbreak of the 
eruption. Tries to escape, struggles to get out of bed (bell., 
rhus). Dryness of the throat with violent thirst, especially for 
sour drinks (bry.). Constant restlessness with jerking motions 
of the limbs and of the whole body. Difficult deglutition from 
spasmodic constriction of the throat (bell., hyos.). 

Sulphur. — Coryza with stoppage of the nose. Itching and 
burning in the nostrils, as if sore. Stitches in the throat when 
swallowing (bell.). Dry cough in the evening on lying down, 
with itching in the bronchi. Stitches in the chest extending 
back to the left scapula (kalicarb. ). Sudden arrest of breathing 
when turning in bed. Chronic cough with mucous rales. Chronic 
discharge from the ears with hardness of hearing. Chronic 
diarrhea. 

Tartar emet. — Chilliness with sneezing, fluent coryza, and 
loss of taste and smell. Much rattling of mucus in the chest 
(ipecac). Cough followed by yawning (mix), especially in 
children. Gastric symptoms. Cyanosis (cuprum). 

Yeratrum alb. — Difficult respiration with tightness and con- 
striction in the chest. Deep, hollow cough, occurring in shocks. 
Icy coldness of the forehead, nose and extremities. Tardy and 
pale livid eruption. Frequent, weak, intermittent pulse. Sud- 
den sinking of strength (ars.). Capillary bronchitis (bry., 
chel., tartar emet.). 

Yeratrum vir. — Severe frontal headache with vomiting. 
Restless sleep with dreams of being drowned. Yellowish or 
whitish coating on the tongue with a red streak down the center. 
Violent nausea and vomiting with pain in the epigastrium. Ir- 
regular, hard, frequent pulse. The heart beats rapidly when 
turning over in bed (bell). Oppression of the chest with slow, 
labored breathing. Convulsions before the eruption. 

HYGIENIC AND DIETETIC TREATMENT. 

The patient should be put to bed and kept in a warm and even 



398 LECTURES ON FEVERS. 

temperature of between 65° Fahr, and 70 c Fahr., until the dis- 
appearance of the eruption. The room should be moderately 
darkened and well-ventilated, care being taken to avoid all 
draughts. Quietude and absolute cleanliness should be insisted 
upon. 

When the skin is dry and hot, frequent, warm, carbolized 
sponge baths, followed by careful drying, may be of service. 
Cold bathing should be sedulously guarded against for fear of 
pulmonary complications. Night and morning inunctions with 
mildly carbolized cosmoline, almond oil, or a piece of warm, fat 
bacon (previously soaked in water to remove the salt), tend to 
reduce the fever and diminish the danger of communicating the 
disease. The ophthalmia, when marked, may be relieved by 
simple warm water or milk and water lotions, or by an ointment 
of ver atria (ver atria five to seven grains, simple cerate one ounce). 
Vapor inhalations are of service when laryngeal symptoms are 
prominent. The lung complications may require the application 
of warm poultices to the chest. 

The diet should be light and unstimulating. Chicken broth, 
milk, milk and arrowroot, and warm drinks should be given at 
first, until the eruption begins to fade. Cool drinks in small 
quantities, may be allowed if desired. When symptoms of ex- 
haustion threaten, either brandy or sherry wine and egg ( pre- 
pared by beating up a raw, fresh egg, and stirring with it one 
tablespoonful of brandy or two tablespoonfuls of sherry wine), 
or beef essence (p. 190), may be needed. 

During convalescence, to avoid taking cold, warm clothing, 
with rlannel next to the skin, should be worn. Patients should 
remain indoors as long as the stage of desquamation or the 
cough lasts. 



LECTUEE XXVII. 

German Measles, 

Definition. — German measles is an acute, contagious, eruptive 
disease of a benign nature, occurring in general or limited epi- 
demics. It is characterized by irregular, slightly elevated, hy- 
peraemic, pale rose red blotches, varying in size from a pin's head 
to a split pea, which, as a rule, appear suddenly, and in light 
cases disappear within two or three days, usually with but slight 
desquamation. It is attended by slight sore throat, slight coryza, 
and but little constitutional disturbance. Its average duration 
is from five to seven days. Second attacks are exceedingly rare. 

Synonyms. — Kotheln. Hybrid measles. Mock measles. Epi- 
demic roseola. Rubeola notha. Scarlatina morbillosa. French 
measles. Hybrid scarlatina. 

History. — German measles was first described by German 
writers in the early part of the present century, under the name 
of " rubeola" by which name it is still known in Germany. 

Cases are reported as having occurred in Boston in 1845, in 
New York in 1873-74, in Philadelphia in 1875, and in German- 
town, Pa., in 1878. 

A wide-spread epidemic occurred in 1880-81, and extended 
throughout nearly all the states of this country. During this 
epidemic the disease prevailed extensively in New York, Chicago, 
Philadelphia and other large cities. 

Etiology. — The nature of the morbific agent of german mea- 
sles is unknown. Though contagious, it is not as much so as is 
that of either measles or scarlet fever. High temperatures are 
supposed to favor its development. 

(399) 



400 LECTURES ON FEVERS. 

The disease belongs essentially to childhood, though it affects 
all ages. According to statistics, it is much more prevalent 
among females than among males. Its type is not constant but 
varies greatly in different epidemics. It affords no immunity 
from either measles or scarlet fever, and but rarely recurs 

Clinical History. — The clinical history embraces a descrip- 
tion of the premonitory stage, the eruptive stage and the desqua- 
mative stage. 

The Premonitory Stage. — In mild cases after an incubation of 
about fourteen days, the disease is ushered in with the eruption. 
In severe cases a premonitory stage, which is of from twenty-four 
to thirty-six hours duration, and is marked by shivering, febrile 
disturbance, headache, sore throat, pain in the back and limbs, 
and in some instances by nausea, short cough, sneezing and 
coryza precedes the appearance of the eruption. 

The Eruptive Stage. — The eruption consists of pale red or 
rosy elevated spots, which vary in size from a pin's head to a, 
split pea or larger. It usually appears upon the face, neck, and 
trunk, and sometimes upon the arms and thighs. At times, the 
pale rose red color is perceptible beyond the line of the lesions 
in the form of a delicate halo. When large, the spots are gen- 
erally distinct, and are seldom arranged in crescentic outline. 
When small, they may be so densely crowded together as to re- 
semble the eruption of scarlet fever. They are oftener conflu- 
ent upon the face than upon any other part of the body, and 
frequently occasion intense itching. After remaining visible, 
from one to two or three days, they rapidly fade and disappear. 

The constitutional symptoms which attend the appearance of 
the eruption are usually slight. Sneezing and coughing are not 
infrequently present. Suffusion of the eyes with injection of 
the conjunctiva is rarely observed. The temperature seldom 
rises above 100. 5 c Fahr. or 101.5° Fahr. In severe cases it may 
reach 102° Fahr. or even 104° Fahr. Defervescence usually be- 
gins on the second day of the fever, and may take place suddenly 
— by crisis, or gradually — by lysis. The pulse usually follows 
the temperature. The fauces are generally somewhat congested, 
and the tonsils may be moderately swollen. The tongue is usu- 
ally covered with a whitish coating, through which a few red and 
enlarged papillae can be seen, especially at the tip. Moderate 



CHAKT. 

CHAET XIX.— German Measles. 



401 



.Nature: Epidemic. Moderately contagious. 


Incubation : Ten to fourteen days. 


Stages: Premonitory. Eruptive. 


Desquamative. 


Duration : 


24 to 36 hours . One to three days. 


One to three days. 


Eruption : 


Appears on 2nd dav. s^XSches^Firs^on Sma11 scales " SJi * ht 
back and chest. brown stains. 


Throat: 


Slight sore throat. glands'S'hmd^terno- Sore throat gradually 
mastoid muscle. disappears. 


Head: 


Headache . Slight headache . 


o 

B 

CO 

I 

H 
O 

o 

"3 
CO 

Hi 

-a 

O 

K 

CD 


Tongue: 


Purred. Marginal 
papillse enlarged. 


Coated Avhite. 


Stomach: Xausea. Anorexia. 


> 

CD F 

ll 

so 

O 

<3 


Extremities: 


Pain in back & limbs. 


Pulse ; 


Accelerated . 


Respiratory 
tract. 


Occasionally catarrh- 
al symptoms Dry, 
hacking cough 


Eyes : 


Slightly suffused. 


Slightly injected. 


Temperature: 


100° to 102 Q . Highest 
on 1st day. 


Usually declines on 
2nd day oi disease. 


Defervescence by 
either crisis or lysis. 


Urine: 


Usually normal. Chlorides in excess. 


Prognosis : 


The prognosis is always favorable. 


Duration : 


Five to seven days. 


Recurrence : 


One attack is protective against recurrence . 



402 



LECTUPiES ON FEVEES. 



swelling of the cervical and post-cervical glands occurs in most 
cases. 

The Desquamative Stage. — The eruption commonly fades in 
from one to two or three days, and may or may not be followed 
by fine branny or f urf uraceous desquamation. The fading erup- 
tion sometimes leaves a slight brown stain, which gradually 
disappears. 

Duration. — The average duration of german measies is from 
five to seven days. 

Morbid Anatomy. — The eruption constitutes the principal 
anatomical lesion of german measles. It is characteristically 
fugitive in character, and rarely remains visible longer than 
twenty-four or forty-eight hours. Exceptionally it continues 
visible for three or Eour days. Twelve hours is the limit of its 
most marked development. 

The irregular, light-red spots or hypersemic blotches are due 
to capillary hyperemia of the papillary layer. They are usually 
distinct; not infrequently they are crowded together, as on the 
face and trunk. As they disappear, very faint and transient 
pigmentations may remain, and minute epidermic scales may be 
shed. Occasionally, vesicles resembling miliaria make their ap- 
pearance upon the hypersemic spots, especially upon the back. 

Differential Diagnosis. — The differential diagnosis of ger- 
man measles is usually unattended with difficulty, when the his- 
tory of the case is taken into consideration. The only diseases 
with which it may be confounded are scarlet fever, measles and 
roseola. 

The chief characteristic points between germtm measles, and 
scarlet fever and measles, are shown in the accompanying table. 



MEASLES. 

Highly contagious. 
Incubation, 7 to 14 days. 
Stage of invasion, 3 days. 

Eruption consists of pa- 
pules, arranged in cres- 
centic patches. 



GERMAN MEASLES. 

Moderately contagious. 

Incubation, 10 to 14 days. 

Appearance of rash often 
the first symptom. 

Eruption consists of pea- 
sized, slightly raised 
patches. 



SCAKLET FEVER. 

Very contagious. 
Incubation, 4 to 7 days. 
Stage of invasion, 2 days. 

Eruption consists of mi- 
nute red points, on a 
biight red hypersemic 
ground. 



TREATMENT. 



403 






MEASLES. 

Dull, raspberry red color. 

First appears on forehead 
and face. 

Duration of eruption, 3 
days. 

Slight sore throat. Dark, 
red spots on palate. 

Glands of throat not en- 
larged. 

Tongue furred white.* 

High fever, with general 
catarrhal symptoms. 

Cerebral symptoms rare. 

Slight, branny desqua- 
mation. 

Recurrences are rare. 

Affords no immunity 
from german measles. 



GERMAN MEASLES. 
Pale, rose red color. 
First appears on back 

and chest. 
Duration of eruption, 2 

to 3 days. 
Slight sore throat. 

Enlargement of cervical 
and post-cervical glands 

Tongue slightly furred. 

Slight fever, with or 
without catarrhal 
symptoms. 

Cerebral symptoms ab- 
sent. 

Slight desquamation in 
small scales. 

Recurrences are rare. 

Affords no immunity 
from measles or scarlet 
fever. 



SCARLET FEVER. 

Bright red color. 

First appears on neck 
and chest. 

Duration of eruption un- 
certain. 

Inflammation of throat. 

Glands of throat en- 
larged and painful. 

Strawberry tongue. 

High fever, hot skin r 
rarely with catarrhal 
symptoms. 

Cerebral symptoms fre- 
quent and grave. 

Copious desquamation in 
large flakes. 

Recurrences are rare. 

Affords no immunity 
from german measles. 



From roseola, german measles may be distinguished by the 
absence of coryza in the latter, and by the glandular enlargement 
which occurs in the former. German measles is, roseola is not, 
contagious. 

Prognosis. — The prognosis is always favorable. 

Treatment. — The treatment consists largely in regulating the 
diet, and in protecting the patient against premature exposure. 
Tepid sponging is useful in allaying the annoying itching, and 
as the eruption fades, inunctions of the surface prove beneficial. 

Aconite is almost the only remedy required. Belladonna may 
be of service if the throat symptoms become marked. Kali bich. 
will be needed when hoarseness, cough and catarrhal symptoms 
are present. Mercnrius may be used for the swelling of the 
glands; and sulphur during desquamation. (For leading indi- 
cations, consult the treatment of measles and scarlet fever.) 



LECTUKE XXVIII. . 

Scarlet Fever. 

Definition. — Scarlet fever is an acute, epidemic, contagious, 
eruptive fever, produced by poisonous emanations — containing 
jolax scindens — from an infected individual, characterized by a 
scarlet red rash on the body and extremities, accompanied with 
fever and an inflammation of the throat. It runs its course in 
from seven to ten days, and ends by desquamation, which usu- 
ally lasts about two weeks. It chiefly affects children, and usu- 
ally occurs but once in the same person. The incubation varies 
from three to eight days. 

Synonyms. — Scarlatina (from "scarlatta," a red-colored cloth). 
Febris anginosa. Fother gill's sore throat. Garotillo. 

History. — Scarlet fever is supposed to have invaded the world 
soon after small-pox and measles. The first record is of an epi- 
demic angina with scarlet eruption, which raged in Spain in 
1610, and extended to Italy in 1618. 

It appeared in Germany about 1625, and was first described 
in England by Sydenham, who established its specific nature 
in 1676. In its mild form it first reached Scotland in 1680. 
Morton described it as appearing in London in 1689. 

In 1735, it made its first appearance in this country at Kings- 
ton, about fifty miles from Boston. Like most new diseases, it 
baffled, for a time, every attempt to check its progress. 

In 1747-49 a severe epidemic prevailed in London, and spread 
to Plymouth in 1751-53. 

In 1778, an epidemic devastated Birmingham. 

It first appeared in Iceland in 1827, in South America in 1829, 
in Greenland in 1847, and in Australia in 1849. 

(404) 



ETIOLOGY. 405 

During the last twenty years it has prevailed in more or less 
extended epidemics in this country. 

It appears to prevail to an unusual degree every fifth year. 

Etiology. — The causes of scarlet fever are, predisposing and 
exciting. 

1. The Predisposing Causes. — The season of the year appears 
to exert some influence. The disease may prevail at all seasons, 
but is most frequent in spring and summer, next in autumn, and 
lastly in winter. 

Age is of great importance among the predisposing causes of 
scarlet fever. The greatest susceptibility is between the ages of 
three and five j T ears. Children under two years, and infants at 
the breast, though by no means insusceptible, are rarely affected. 
After the fifth year the liability rapidly diminishes and becomes 
very small after forty. 

Sex exerts little influence as a predisposing cause. Statistics 
show a marked preponderance in the number of males attacked 
during the first ten years of life. After fifteen years of age, 
females are more susceptible than males. As contrasted with 
measles, scarlet fever is generally lighter in proportion to the 
age of the patient. 

2. The Exciting Cause. — The real nature of the scarlet fever 
poison is no longer unknown. Eklund's discovery of minute 
organisms — plax scindens — in the blood and urine of scarlati- 
nous patients, threw a flood of light upon this subject. Since 
the announcement of his discovery, other microscopists have 
found by systematic examination of the blood and urine of scar- 
let fever cases, that these micro-organisms are constantly present 
in, and peculiar to, the fluids of this disease. As contained in 
the urine, Dr. Ekluncl describes the plax scindens, as consisting 
of flat, oval or rounded, colorless or yellowish-white sporoiclal 
cells, having a distinct cell wall, and a clear brownish-colored 
nucleus. As a rule, they are found free, and never arrange them- 
selves either in swarms or in rows as do ferments. They multi- 
ply by binary fission, and frequently exhibit rotary or screwing 
motions. 

Up to the present time plax scindens have not been found in 
any other fever. The conclusion is inevitable that this parasite 
has to do with th& causation and development of scarlet fever; 
or, in other words, that it constitutes the contagion of the disease. 



406 LECTURES ON FEVERS. 

The contagiousness of scarlet fever is clearly demonstrated by 
both clinical observation and experimental inoculation. Miquel, 
Stole and Williams have succeeded in artficially infecting 
healthy individuals by inoculating them with either the blood or 
the epidermic scales taken from scarlatinous patients. These 
inoculations were followed not only by the characteristic febrile 
eruption, but were more severe than the ordinary disease, and 
appeared to confer a certain degree of protection from reinocu- 
lation. 

The period at which the disease is most contagious is at the 
height of the fever, when the parasite is found in greatest quan- 
tity in the urine. It may also be conveyed during the desqua- 
mative period in the epidermal scales. The atmosphere may be 
contaminated not only by the air exhaled by scarlet fever pa- 
tients, but also by the secretions, especially the urine. The 
distance to which the poison may be carried by the air does not 
exceed a few feet. It enters the system mainly by the lungs, 
although drinking milk which has been diluted with water, prob- 
ably containing plax scindens, may cause the disease. The most 
frequent mode of infection is by breathing the air of a room 
occupied by a scarlet fever patient. It may also take place 
without direct communication, and persons may carry scarlet 
fever to others without becoming affected themselves. In order 
to thus convey the poison it is necessary that the clothing be- 
come thoroughly saturated with it, and physicians in simply 
making their daily visits are in no danger of carrying the disease. 
It retains its vitality for a long time, and may attach itself to 
clothing, bedding or furniture, which act as fomites. 

The contagion of scarlet fever is less tenacious than that of 
either measles or small-pox. Prolonged exposure to moderately 
dry heat (204° Fahr.) destroys it. 

The period of incubation is shorter than in the other eruptive 
fevers, and varies from two to ten days. Its average duration is 
from four to seven days. 

Immunity from a second attack is enjoyed by a majority of 
persons who have suffered from scarlet fever. Nevertheless, 
many cases of well-marked second attacks are recorded. Sec- 
ondary or tertiary attacks are rarely fatal. 

The lower animals, especially the cat, dog, horse and hog, are 
liable to have scarlet fever. Many cases occurring in the human 



CLINICAL HISTORY. £07 

subject, and heretofore supposed to have originated de novo or 
independent of infection, were probably due to transmission of 
the disease from these animals. 

Forms. — Scarlet fever may be either mild or severe. 

1. The mild or ordinary form represents the general course of 
the disease, and will be fully described in the clinical history. 

2. The severe or malignant form is characterized either by the 
extreme gravity of the throat symptoms, or by the early involve- 
ment of the cerebro-spinal system in consequence of some pecu- 
liarity of the morbific agent, high temperature, septic or ursemic 
poisoning, or extreme susceptibility of the organism. 

Clinical History. — The clinical history embraces a descrip- 
tion of the stage of invasion, the stage of eruption, and the 
stage of desquamation. 

The Stage of Invasion. — The prodromal stage or stage of in- 
vasion is usually ushered in suddenly, by a chill or chilliness, 
alternating with burning heat, followed by a rapid rise in tem- 
perature, which often reaches 104° Fahr. within twelve hours. 

The skin becomes exceedingly dry and pungent, the face 
flushed, and the pulse rapid and bounding. Pain in the head, 
vomiting and thirst are early and prominent symptoms. The 
tongue is thickly coated white, the filiform papillae are enlarged 
and project through the coating, and the whole presents the appear- 
ance of a white strawberry. There is a diffuse redness of the pil- 
lars of the fauces, uvula and tonsils, with slight soreness of the 
throat. The eye assumes a peculiar brilliant and glistening 
stare. In children there may be syncope, delirium or convul- 
sions. The average duration of this stage is from twelve to 
twenty-four hours; it may be prolonged to four or five days. 

The Stage of Eruption. — Usually on the second day of the 
fever an eruption appears about the neck and clavicular regions, 
and extends rapidly — within ten or twelve hours — over the en- 
tire surface of the body. It is first seen as minute red dots or 
specs, which vary in size from a line to a line and a half in di- 
ameter. These dots, which are not elevated above the surface, 
run together and form patches which rapidly coalesce. 

After the second day of the eruption, the whole cutaneous 
surface presents a bright rose red appearance in mild cases, and 
a deep red or boiled lobster appearance in severer cases. The 



408 LECTURES ON FEVERS. 

rash is usually most intense upon the back and loins. Upon the 
extensor surface of the limbs it is often developed in punctate 
form, and imparts to the skin a certain degree of roughness. 
The redness which momentarily disappears on pressure, rapidly 
returns from the periphery to the center of the spot, the instant 
the pressure is removed. As the eruption becomes fully devel- 
oped, the skin, especially on the face, hands and feet, appears 
slightly swollen. Frequently there is more or less itching and 
burning over the entire surface. The eruption usually attains 
its maximum of development upon the evening of the fourth 
day and remains visible six days. In extremely mild cases it 
may not last longer than two or three days. 

The febrile and other symptoms which preceded the eruption 
persist unabated, and are often augmented. The temperature 
may continue to rise until it has reached 106° Fahr. or 107° 
Fahr.— usually not higher than 103° Fahr. or 105° Fahr. The 
pulse is quick, full and vibratory, and ranges from 120 to 140 or 
even 160 per minute. Vomiting becomes more severe and is 
projectile in character. Thirst is usually urgent and anorexia 
is generally present. The skin is dry, and the heat is intense 
and pungent. The condition of the fauces is characteristic. In 
some very mild cases, there is simply redness over the tonsils, 
pillars of the soft palate and uvula. In most cases there is more 
or less parenchymatous inflammation of the tonsils with general 
tumefaction of the soft parts of the throat. Occasionally ulcer- 
ation of the tonsils takes place. Not infrequently the glands 
about the neck are somewhat swollen and tender. The tongue, 
which early in the disease is generally coated, may shed its coat- 
ing and appear clean and reddened, the enlarged papillae giving 
to it the so-called " strawberry " or " cat's tongue " appearance. 
The urine is scanty and turbid, often high-colored, and is defi- 
cient in chlorides; occasionally it contains albumen and bile 
pigment. Not uncommonly there is some delirium, especially 
at night. The duration of this stage varies from four to six 
days; it may be prolonged to eight or ten days. Usually from 
the fifth to the eighth day of the eruption, as the rash fades, 
— leaving a brownish-yellow pigmentation of the surface — the 
temperature begins to decline, the pulse lessens in frequency, the 
redness aud swelling of the tonsils diminish, the throat symp- 
toms abate, and the tongue gradually returns to its normal state. 



MALIGNANT SCAELET FEVER. 409 

The Stage of Desquamation. — Desquamation often commences 
with the decline of the eruption, and is usually slight or exten- 
sive in proportion to the intensity and diffusion of the rash. It 
commences first on the neck by a loosening of the epidermis in 
the form of thin, light scales, and gradually extends over the 
whole body. On the extremities it is frequently exfoliated in 
large flakes. Occasionally the cuticle of the hands and feet is 
detached entire. The hairs may be simultaneously shed. The 
mucous membrane also participates in the exfoliating processes. 
During this stage the urine becomes abundant and pale, and 
often contains albumen. The period of desquamation lasts from 
ten to sixteen days, at the end of which time if neither compli- 
cations nor sequels occur, the patient is convalescent. 

Duration. — The duration of scarlet fever in uncomplicated 
cases, is from two to four or six weeks. 

Severe or Malignant Scarlet Fever. — The severe or malig- 
nant form of scarlet fever is usually marked by irregularities in 
the manifestations of the disease. In some cases the symptoms 
set in suddenly and are of a most violent character. In others, 
grave symptoms do not appear until the third, fourth or fifth 
day. In the majority of instances more or less severe and dan- 
gerous symptoms develop during or immediately following the 
onset of the attack. 

In one class of cases, marked by early high temperature, there 
is not much swelling of the throat, nor very marked increase in 
the frequency of the pulse, but on the second day of the erup- 
tion the thermometer in the axilla registers 107° Fahr. or 108° 
Fahr. 

In another class of cases, the throat symptoms are promi- 
nent from the onset of the attack. The fauces are of a deeper 
color and more swollen than in the ordinary form, and there is 
more difficulty in swallowing. TVhitish or yellowish ash-colored 
points or patches appear upon the soft palate and tonsils. These 
membranous spots may remain from one to three or four days 
and then disappear, or they may form in successive crops. The 
mucous membrane underneath may be red and swollen, or even 
softened and ulcerated. There is usually more or less fetor of 
the breath. Occasionally the tonsils are enlarged, infiltrated 
with pus and softened. The pharynx may appear ulcerated, and 



410 LECTUEES ON EEVEES. 

in very malignant attacks may present evidences of gangrene. 
Inflammation and swelling of the sub-maxillary lymphatic glands 
and surrounding cellular tissue almost invariably occurs. In 
favorable cases the enlargement and induration of the glands 
disappear in from three to twelve days, in others it terminates 
in suppuration. Purulent or membranous coryza and often 
otorrhoea, which is apt to result in permanent deafness, are 
present. 

In still another class of cases the patient may perish shortly 
after the onset of the attack, and before the eruption appears, 
exhibiting comatose or convulsive symptoms, from the over- 
whelming of the cerebro-spinal system with the scarlatinous 
poison. Or the eruption may partially appear and then recede 
or assume a livid, hemorrhagic or petechial type, and be followed 
by albuminuria, diarrhea, coma and death. 

Either septic or ursemic poisoning may cause a case of scarlet 
fever, which has been running a benign course, to suddenly 
assume a malignant type. The uraemia in such cases is due to 
the development of scarlatinal nephritis, and the septic poison- 
ing is due to a septic element in the ichorous discharges from 
the nostrils, or to a septic poison developed during the suppura- 
tive process which occurs when immense cervical abscesses are 
formed. 

The general symptoms are of necessity more severe in malig- 
nant than in ordinary cases. The fever is usually intense, al- 
though in hemorrhagic cases the temperature is not always 
specially high. There is great restlessness with depression of 
strength, and a decided tendency to delirium and stupor; at times 
stupor or coma may alternate with convulsions. The respirations 
are accelerated, and the pulse ranges from 140 to 150 or even 170 
beats per minute. In most instances, especially if throat symp- 
toms are pronounced, a loud gurgling noise is heard in the throat 
when the patient is asleep or dozing. Nausea and vomiting are 
usually prominent. In severest cases there may be diarrhea. 
The face is deeply flushed and anxious. Laryngitis not infre- 
quently occurs, evidenced by frequent, hoarse or croupal cough, 
aphonia and dyspnoea with stridulous respiration. Usually 
within four or five days, if no improvement takes place, the pa- 
tient lapses into a typhoid condition and dies in from three to 
ten days. 



COMPLICATIONS AND SEQUELS. 411 

The duration of severe or malignant cases of scarlet fever is 
uncertain. Life may be destroyed in a few hours or the patient 
may linger for several days, sometimes for two, three or even six 
weeks. The average duration is from eighteen hours to five or 
six days. 

Irregularities. — At times the eruption appears first upon the 
extremities and trunk, and afterwards about the neck and clavic- 
ular regions. It may be either short lived or unusually pro- 
longed. Miliary papules, minute vesicles or purpuric lesions 
may appear upon the affected surface. Occasionally, during the 
prevalence of scarlet fever epidemics, the only local manifesta- 
tion of the disease is the sore throat, no eruption appearing. 
Such cases have been termed scarlatina sine erupt ione, and are 
capable of imparting the regular form of the disease to others. 
Another irregularity consists in the development of an eruption 
without fever or throat symptoms. Some writers, with doubtful 
propriety, make mention of a latent scarlet fever, which is marked 
by the absence of throat, cutaneous and febrile manifestations, 
the only evidence of the occurrence of the disease being the 
appearance of the characteristic sequels. 

Occasionally during desquamation, the skin of the chest ap- 
pears reddened and hyperaemic. Not uncommonly during con- 
valescence a mottled rash, due to the escape of coloring matter 
into the surrounding tissue, appears upon the legs and lasts only 
a few days. Constitutional symptoms seldom attend these rashes. 

Sometimes, as late as four weeks after the first appearance of 
the eruption, in consequence of some septic condition, a soreness 
of the throat with injection of the fauces reappears, accompanied 
by albuminuria and the development of a chest rash, which lasts 
from twelve hours to two or three days. 

Complications and Sequels. — The most common sequel of 
the disease is scarlatinal dropsy. It attacks mostly the sub-cu- 
taneous tissues, when it is known as anasarca. Not infrequently 
it affects the serous cavities and the internal organs, and causes 
oedema of the lungs, ascites, hydrothorax, hydropericardium or 
hydrocephalus. 

Anasarca is present in about one-fifth of all cases, and usually 
occurs in the course of the second or third week of the disease, 
during the process of desquamation, or just as desquamation is 



412 LECTURES ON FEVERS. 

being completed. It follows moderate oftener than severe cases, 
and is produced by changes in the kidneys, mainly induced by 
some peculiarity in the scarlet fever poison, although commonly 
believed to be due to the influence of cold. It first shows itself 
in the face, and is most marked about the eyelids. From the 
face it extends over the body, and if it becomes general is apt to 
be attended by more or less ascites. 

Frequently for two or three days before the occurrence of the 
anasarca, the patient is restless and sleepless, and complains of 
pain in the head, anorexia, nausea and vomiting. The skin be- 
comes hot and dry, and the temperature is raised two or three 
degrees. The urine is high-colored and scanty, and if examined 
will be found to contain albumen and exudative casts. 

In mild cases after the anasarca has continued for two or three 
days it begins to decline, the general symptoms disappear, and 
the urine returns to normal. In more severe cases it is apt to 
become extensive and may remain for a week or ten days. In 
violent cases it steadily increases, puffiness of the face and 
oedema of the limbs become more and more marked, the tem- 
perature steadily rises, and the urine becomes scanty or is en- 
tirely suppressed. If the disease is not removed, the effusion 
may extend to the serous cavities and internal organs. Death 
may occur from coma sometimes preceded by convulsions, due 
to uraemia, from asphyxia occasioned by oedema of the lungs or 
hydrothorax, or from hydrocephalus, 

CEdema of the glottis is a dangerous complication. It not in- 
frequently occurs in connection with extensive suppuration of 
the glands and areolar tissue about the neck. Abscesses about 
the throat are not uncommon in scrofulous subjects. 

Diphtheria is a not very rare complication. It usually appears 
suddenly, and is characterized by the pathognomonic exudation 
and attendant depression of the disease. It may develop at any 
period of the fever, but generally occurs during desquamation. 
Its advent is of serious import, as it usually terminates fatally. 

Bronchitis and pneumonia are rare complications. Pleuritis 
is quite common. 

Endocarditis is the most common inflammation of the serous 
membranes, occurring as a complication of scarlet fever. It is 
usually ulcerative in character, and may give rise to either sep- 
ticaemia or embolism. 



COMPLICATIONS AND SEQUELS. 413 

Pericarditis may occur, but is not as frequently observed as 
is endocarditis. 

Peritonitis is a rare complication. When it does occur, it is 
apt to be sub-acute. 

Gasti'o-intestinal disorders are not uncommon. AYhen severe 
or long continued, they may prove dangerous. 

Catarrhal and parenchymatous nephritis are important and 
justly dreaded complications during the stage of desquamation. 

Rheumatism, of an inflammatory character, sometimes occurs 
during the desquamative period. It usually travels rapidly from 
one joint to another, and seldom lasts longer than four or five 
days. Suppurative synovitis is recorded among the occasional 
sequels. 

Phlyctenular conjunctivitis is the most frequent eye complica- 
tion. Paralysis of the ciliary muscle and loss of power of ac- 
commodation sometimes occur as a sequels. Occasionally de- 
struction of the cornea occurs, as a result of severe keratitis. 

Otitis is a not uncommon sequel. It may be either external, 
middle or internal, and is generally due to the extension of the 
inflammation up the Eustachian tube. Sometimes it terminates 
in ulceration and destroys the tympanum, and even the ossicles, 
and may induce caries of the mastoid process of the temporal 
bone. It is apt to be associated with more or less permanent 
deafness, and may prove fatal by the eventual production of 
meningitis or even abscess of the brain. 

Chronic and purulod nasal catarrh, which may result in 
caries of the nasal bones, is a not uncommon sequel. 

Chorea occasionally appears during convalescence. 



LECTUKE XXIX. 
Scarlet Fever.— (Continued.) 

ANALYSIS OF CHAKT. 

The Nervous System.— A chill or chilliness is an initial 
symptom in some cases of scarlet fever. Frequently, however, 
it is absent or but feebly marked. 

Headache occurs among the earlier symptoms. It is often 
only moderately intense, sometimes it is slight. Rarely, it aug- 
ments during the eruptive stage. Generally it terminates upon 
the advent of delirium. 

Pains in the back and limbs are prominent symptoms during 
the early days of the attack. There is frequently some tender- 
ness about the joints. 

Delirium, manifested by incoherency, is present in all severe 
cases. Occasionally in malignant cases delirium and coma usher 
in the disease. Active delirium, carphologia and subsultus ten- 
dinum, characterize severe cases. 

Restlessness, jactitation and sleeplessness, are apt to be more 
or less marked. 

Drowsiness, verging gradually into coma, often exists in severe 
cases from the start. 

Great debility is an early symptom in malignant cases. It not 
infrequently remains as a sequel in other cases. 

Coma occurs in by far the greatest number of fatal cases, and 
is generally the forerunner of death. In violent cases it fre- 
quently alternates with convulsions. Occasionally coma appears 
suddenly in consequence of embolism of one of the cerebral 
vessels, in patients who before this occurrence appeared to be 
doing well. 

(414) 



CHAET. 

CHAET XX.— Scarlet Fever. 



415 



Nature : 



Epidemic. Contagious. Portable. 



Incubation: 



Three to eight days. 



Stages: 



Invasion. 



Eruption. 



Desquamation 



Duration : 



12 to 24 hours. 



Four to six days. ; 10 to 1(5 days 



Skin: 



Dry, pungent heat. 



Scales or 



Fine scarlet rash. First 
on neck and clavicles. 

Itching. jflakes. Itching 



Temperature : 



103° to 104' 



103" to 105° or 107°. 



Gradual defer- 
vescence. 



Pulse: 



100 to 120 or 140. 



120 to 140 or 160. 



Returns to 
normal. 



Nervous System 



Throat 



Sore throat, Redness oi 
tonsils, palate and uvula. 



Inflammation of tonsils. 

Ash-colored exudation. 

Swelling of external 

glands. 



Pain in the head. Con- 
vulsions. 



Headache. Nocturnal 
delirium. 



Stomach: 



Nausea and vomitinj 



Projectile vomiting, j 
Thirst. 



CO 

if 

O 2! 



Tongue: 



White coating. 



Strawberry tongue . 



Urine: 



High colored. 



Scanty, Dark. Contains £j£ n gSg g£ 

piax scindens, often al-P^^^ 8 



bumen and casts . 



casts. 



Eyes : 



Ears : 



Brilliant and glistening. Conjunctivitis. 



Normal. 



Otitis. 



Eye and ear 
sequels. 



Complications 
and Sequels : 



Anasarca. Dropsy. Inflammation of serous membranes. 
Rheumatism . Eye and ear lesions. Diphtheria. 



Duration: 



From two to four or six weeks. 



Recurrence : 



Scarlet fever seldom recurs . 



Age : 



Mostly from two to five years . 



416 LECTUliES ON EEVERS. 

Convulsions often usher in the attack in children. 

Paralysis is not of common occurrence. 

Cases that begin with violent nervous phenomena, and are 
afterwards characterized by the appearance of severe throat 
symptoms, usually terminate fatally. 

The Temperature. — In all cases of tolerably severe scarlet, 
fever the temperature rises rapidly, and may reach 103 ^ Fahr. 
or 104 u Fahr. within a few hours. It increases, as a rule, with 
the appearance of the eruption, and remains between 104° Fahr. 
and 106° Fahr, until the rash begins to decline. At times it is 
hyperpyretic, and reaches 107° Fahr. or 108° Fahr. on the second 
day. It runs high in malignant cases, and has been known to 
exceed 112° Fahr. in fatal cases. 

Defervescence is frequently irregular and may be delayed by 
complications. The temperature-fall dates from the decline of 
the rash, and generally requires from three to eight days for its 
completion. Exceptionally, after a moderate exacerbation, it 
reaches the normal in twelve hours. Occasionally it takes the 
zigzag descent of lysis. A sub-normal temperature sometimes 
sets in before the normal is rendered certain. In some cases the 
temperature pursues a descending course while all the severe 
constitutional symptoms continue, the patient dies whilst the 
temperature falls still lower, or undergoes fatal perturbations. 
Its descent may be interrupted by renewed exacerbations, usually 
traceable to some complications. In typhoid states it may re- 
main high for ten days or two weeks after the fading of the rash. 

During convalescence it remains normal unless elevated by 
complications. In fatal cases, if death occurs during the stage 
of eruption, the temperature ranges high until death approaches 
when it generally falls. If death takes place during the decline 
of the eruption, the temperature may either rise or fall in the 
death agony. 

The Pulse. — The frequency of the pulse is a marked symp- 
tom in scarlet fever. It frequently reaches 120 or 140 soon after 
the onset of the attack, and is full and compressible. In severe 
cases it may run up to 150, 160 or even 170. As the disease 
progresses towards a fatal termination it becomes small and very 
rapid, and is often uncountable. 

The Respiratory System . — The respirations are generally 






THE THROAT. 417 

natural, although when the fever runs high they are somewhat 
quickened. A frequent, guttural, dry cough is often present. 
In severe cases the respirations become accelerated. As a result 
of the throat affection they become labored and difficult, and are 
performed with a noise like that of one strangling- From this 
circumstance is derived the Spanish name for the disease, garo- 
iillo. The voice is apt to be hoarse, and in severe cases may 
become whispering or lost, in consequence of extensive exuda- 
tion into the larynx. 

The Throat. — Sometimes a feeling of roughness in the throat 
with pain during deglutition is the first intimation of the ap- 
proach of the disease Exceptionally, in the mildest cases, there 
may be no pain in swallowing, but little redness over the tonsils 
and soft palate, and no inflammation or swelling of the throat. 
In most cases, however, there is more or ]ess swelling of the 
tonsils, and general tumefaction of the soft parts of the throat. 
As the eruption progresses, the fauces become more swollen the 
redness of the mucous membrane deepens, the tonsils become 
the seat of more or less intense parenchymatous inflammation, 
and are frequently spotted with a white or ash-colored exudation. 
This exudation differs from that of diphtheria in adhering less 
closely, in being ash-colored instead of yellows in appearing upon 
a uniformly reddened mucous membrane instead of a simply 
circumscribed redness, and in not coming off in dense membra- 
nous layers. The exudative spots may remain from one to three 
or four days, and are then thrown off permanently. Occasionally 
they form in successive crops. Hawking and spitting are apt to 
be troublesome on account of the collection of mucous in the 
throat and fauces. Fetor of the breath is more or less pro- 
nounced, according as the exudation is slight or extensive. 

In severe cases the exudation may become dark and offensive, 
and leave deep, ragged, ashy-looking ulcers on the throat and 
tonsils. Inflammation, swelling and induration of the lymphatic 
glands and cellular tissues about the angle of the jaw and under 
the chin are almost constant accompaniments. The tumefaction 
may extend to the sides of the neck and throat, and greatly em- 
barrass respiration. In such cases there is great danger of oedema 
of the glottis. Extensive suppuration in the glands and areolar 
tissue about the neck sometimes occurs. Sloughing pharyngitis 
not infrequently occurs in the worst forms. In malignant at- 



418 LECTUEES ON FEVEES. 

tacks there may be evidences of gangrene of the pharynx and 
uvula. 

The Cutaneous Surface. — The skin becomes hot and dry, and 
the face flushed shortly before the onset of the attack. The heat 
is usually pungent in character, and the integument is slightly 
swollen. An indescribable odor — likened by some to that of old 
cheese — readily discernable when once recognized, often attaches 
to the scarlet fever patient, and is an important aid in diagnosis. 
More or less itching and burning attends the cutaneous conges- 
tion, and increases in intensity as the disease progresses. 

The eruption appears on the second day of the fever and con- 
stitutes the characteristic clinical phenomenon of the disease. 
It appears first about the neck and clavicular regions, and ex- 
tends rapidly over the trunk and extremities. It frequently 
spares the face, and the skin about the mouth is usually pallid 
The first appearance is in the form of fine red dots or points. 
These dots form irregular patches of considerable size, which 
quickly coalesce, and give to the skin a distinctly scarlet color. 
In malignant cases the rash comes out late, and is either pale 
and indistinct or dark and livid. In rare instances it is wholly 
wanting. In mild cases it is frequently of short duration and 
occurs only in patches which do not coalesce. It reaches its 
height about the fourth day, and then remains stationary for one 
or two days, after which it begins to decline. It is most vivid 
and remains longest upon the back, loins, inner surfaces of the 
arms and thighs, and flexures of the joints. The surface of the 
eruption is usually smooth; but in some cases, particularly 
upon the extensor surfaces of the extremities, on account of the 
enlargement of the papillae it is slightly roughened. Occasion- 
ally minute miliary vesicles are scattered over the surface. 

Desquamation usually commences about the sixth day, first 
upon the neck, and then gradually extending over the body. 
Where the skin is thin, the epidermis comes off in thin, light 
scales. Where it is thick, as on the palms and soles, it peels off 
in large flakes. As the rash fades it leaves a yellowish-brown 
pigmentation which gradually disappears. In severe cases the 
hair falls off, as in all long fevers. 

The Digestive Tract.— The tongue is at first coated white or 
yellowish-white and is of a deep-red color at the tip and edges. 



THE URINE. 419 

During the eruptive stage the coating exfoliates, and the whole 
surface assumes a deep red and shining aspect. The papillae 
become enlarged and projecting, and cause the tongue to present 
the appearance of a ripe strawberry. This strawberry-like or 
cat's tongue is usually present in all well-marked oases, and is 
pathognomonic of the disease. It frequently continues for a 
week or ten days and then returns to normal. The tongue is usu- 
ally moist throughout the attack. In malignant and fatal cases it 
becomes dry, brown and chapped, and sordes collect upon the 
lips, teeth and gums. Thirst is usually urgent, and there is 
complete anorexia. Nausea and vomiting occur in the majority 
of cases, and are more urgent during the eruptive stage. They 
become violent and constant in severe cases. The bowels are 
natural or else slightly constipated in ordinary cases. At times 
a slight gastro-intestinal catarrh may be present. Colliquative 
diarrhea and intestinal hemorrhage occasionally occur in malig- 
nant cases. 

The Urine. — The urine is commonly of a deeper color than 
in health, and contains plax scindens and a large quantity of 
lateritious sediment. It is generally acid in reaction, and its 
specific gravity is higher than normal. The quantity of urea 
and chlorides is usually diminished. Albumen is present in 
over half of the cases. Renal epithelium, epithelial or hyaline 
casts, and blood globules, are apt to be more or less abundant in 
the sediment. 

In severe cases the urine may be very scanty, or even entirely 
suppressed, and is frequently attended by uraemic symptoms. 
"Usually whatever urine is voided is of a dark-red or blackish- 
brown, smoky color. The specific gravity runs high — 1025 to 
1040 — and the amount of albumen, casts and blood globules is 
large. After a time, in favorable cases, the urine becomes more 
abundant, the smokiness and albumen disappear and the specific 
gravity gradually returns to normal. In less fortunate and by 
no means rare cases, the albumen remains constant, and the mi- 
croscope shows granular or epithelial casts, and free renal epi- 
thelium. 

The Special Senses.— The eye and ear are frequently involved 
and are often the seat of serious lesions. 

Conumctivitis may occur at any sta^e. Phlyctenular innam- 



420 , LECTURES ON FEVERS. 

mation is a not uncommon sequel. Marginal blepharitis fre- 
quently exists and is apt to become chronic. Primary keratitis 
may occasion perforation of the cornea. Transitory blindness 
often accompanies the ordinary symptoms of uraemia. 

Catarrhal Eustachian deafness and external otitis are not 
uncommon when the rash is well marked. Acute suppurative 
otitis media is oftener present when the throat symptoms are 
prominent, and when the cutaneous manifestations are less 
marked. 

The nasal mucous membrane is frequently the seat of an ex- 
coriating coryza, which is often associated with a dangerous 
form of pharyngitis. The discharge contains the elements ca- 
pable of producing septic poisoning . Not infrequently it leads 
to the formation of ulcers, and eventually necrosis of the nasal 
bones. 

Morbid Anatomy. — The characteristic lesion of scarlet fever 
is to be found upon the skin and mucous membrane. Most im- 
portant changes may also be observed in the blood, kidneys, liver, 
spleen and lymphatic glands of the throat. 

The Skin. — The morbid changes which take place in the skin 
are mainly those of hyperemia and slight exudation, and are 
believed to be due to the irritating nature of the plax scindens* 
The hyperemia is limited for the most part to the corium and 
papillary layer, In the early stages the corium presents signs 
of inflammatory oedema with enlargement of the papiDse, and 
the whole is somewhat thickened. Later the thickening becomes 
less marked, but local thickenings of the stratum lucidum and 
partial loosening of the stratum corneum are found. These 
changes usually take place previous to the separation of large 
masses by desquamation. The process of desquamation may 
last only a few days, or it may continue for weeks. It is not a 
rare thing for it to recur a second time on the same surface. 

The eruption, which is usually referred to as the characteristic 
cutaneous lesion, consists of pin-head sized, closely placed points, 
between which the skin is of a natural color. In well-marked 
cases the surface is swollen and intensely congested, and presents 
a generally reddened appearance. The spots are mainly circular; 
at times they are elongated, especially on the forearms and legs- 
The color of the eruption varies from pale red to dark red, and 
is, as a rule, proportionate to the intensity of the fever. It is 



MORBID ANATOMY. 421 

a result of the congestion and inflammation of the skin, which 
may be presumed to be due to the irritant pressure of the plax 
scindens. 

Occasionally the eruption is accompanied or followed by acne, 
herpes or urticaria. Not infrequently in malignant cases, cuta- 
neous hemorrhages occur, which lead to the formation of pe- 
techia and extensive ecchymoses. 

The blood undergoes various changes, and usually contains 
plax scindens. 

The mucous membrane of the tonsils and pharynx is red and 
swollen at the onset of the disease. Soon the parts become cov- 
ered with a tenacious mucus, and small elevations appear upon 
the reddened surface. In severe cases the secretion becomes 
abundant and the membrane appears dark and cedematous, and 
may appear more or less covered with ash-colored patches. At 
times the membrane becomes ulcerated and softened. In ma- 
lignant cases gangrene of the pharynx may occur. 

Inflammation of the parotid and sub-maxillary lymphatic 
glands, and of the surrounding cellular tissue is frequently en- 
countered. It may terminate in resolution; not uncommonly it 
ends in suppuration, and may be followed by extensive destruc- 
tion of connective tissue. 

Purulent catarrh of the posterior nares occurs in severe cases, 
and gives rise to troublesome coryza. 

The eye lesions include conjunctivitis, purulent choroiditis, 
retinitis and suppurating ulcers of the cornea. The ear lesions 
are puriform and are mainly located in the middle and external 
ear. 

The kidneys are, next to the skin and mucous membrane, oft- 
enest affected in scarlet fever. The mildest affection of these or- 
gans is catarrh of the uriniferous tubules, a condition usually 
marked by more or less exteusive epithelial desquamation. Oc- 
casionally a croupous inflammation of the tubules is induced. 
The morbid processes commence at the malpighian bodies and 
extend to the uriniferous tubules. Cloudy swelling of the epi- 
thelial cells characterizes the anatomical changes during the first 
week. Infiltration soon takes place around the tubules, which 
become stuffed with these clouded and enlarged epithelial cells 
or with granular matter resulting from their disintegration. 



422 



LECTURES ON FEVERS. 



Occasionally fatty degeneration of the epithelium occurs. Some- 
times abscesses form in the substance of the kidney. 

Moderate catarrh of the vagina not infrequently occurs. 

The spleen is, as a rule, slightly enlarged. 

The liver changes are similar to those of typhus fever. 

Bronchial catarrh is frequently present during the early and 
late stages of the disease. Lobular broncho-pneumonia some- 
times occurs in severe cases. 

Synovitis often occurs at the commencement of desquamation, 
and most frequently attacks the small joints. When suppurative 
inflammation of the joints occurs, death may ensue from pyaemia. 

The mesenteric, Brunner's and Peyer's glands are not infre- 
quently enlarged and injected. Sometimes Peyer's patches 
present the "shaven-beard appearance" observed during the 
first week of typhoid fever. 

Differential Diagnosis. — The positive diagnosis of scarlet 
fever, though impossible during the stage of invasion, is usually 
attended with but little difficulty after the appearance of the 
eruption. 

The diseases with which it is most liable to be confounded are 
erythema, small-pox, measles, german measles, roseola, erysipe- 
las and diphtheria. 

Erythema is to be distinguished from scarlet fever by the 
damask rose color of the eruption, by the smaller size of the 
patches, by the absence of constitutional symptoms, and by its 
short duration. 

The striking points of differential diagnosis between scarlet 
fever and measles and small-pox are presented in the following 
tabular arrangement: 



MEASLES. 

Very contagious. 

Most common in chil- 
dren. 

Incubation variable, from 
7 to 14 days. 

Duration, 12 to 16 days. 

Prodromal symptoms, las- 
situde, shivering, sneez- 
ing, harsh cough. Rare- 
ly vomiting. 



SCARLET FEVER. 

Contagious. 

Most common in chil- 
dren. 

Incubation uncertain, av- 
erage about 8 days. 

Duration, 2 to 3 weeks. 

Prodromal symptoms, 
shivering, nausea, vom- 
iting, sore throat. Con- 
vulsions occasionally in 
children. 



SMALL-POX. 

Highly contagious. 
Most common in adults. 



Incubation constant, 10' 

to 13 days. 
Duration, 3 to 5 weeks. 
Prodromal symptoms, 

marked chill, followed 

by vomiting and severe 

lumbar pains. 



DIFFERENTIAL DIAGNOSIS. 



428 



MEASLES. 

Eruption appears on 4th 
day. 

Eruption consists of pa- 
pules arranged in a 
creseentic manner on a 
white ground. 

Eruption appears first on 
forehead and face, and 
extends gradually 
downwards. 

Eruption lasts about 5 
days. 

Skin has no peculiar odor. 

Bronchitis and coryza 

very constant. 
Sore throat rare. 

Dark red, irregular spots 
on the palate. 

White coated tongue. 

Temperature, 103° to 

107°. 
Fever rather increased by 

the eruption. 
Secondary fever absent. 

Pulse, 100 to 120 or 160 

Cerebral symptoms very 
rare, and not severe. 

Desquamation slight and 

branny. 
Catarrhal pneumonia a 

frequent complication. 

Sequels; chronic bronchi- 
tis, phthisis and chron- 
ic conjunctivitis. 



SCARLET FEYEE. 

Eruption appears on 2nd 
day. 

Eruption consists of close- 
ly packed, minute red 
points, on a bright-red 
hyperaemic ground. 

Eruption appears first on 
chest and neck, and 
spreads rapidly. 

Eruption lasts about 7 

days. 
Skin has an iL old cheese " 

odor. 
Bronchitis and coryza 

rare. 
Considerable sore throat. 

Marked injection of the 
fauce s. Tonsils en- 
larged and painful. 

Strawberry tongue. 

Temperature, 105° to 

112°. 
Fever not relieved by the 

eruption. 
Secondary fever absent. 

Pulse, 100 to 120, 140 or 
170. 

Cerebral symptoms fre- 
quent and grave. 

Desquamation copious 
and in flakes. 

Pneumonia a rare com- 
plication. Pleurisy 
frequent. 

Sequels; dropsy, conjunc- 
tivitis, deafness and 
glandular enlargement- 



Vaccination affords no Vaccination affords ] 
protection. protection. 



SMALL-POX. 

Eruption appears on 3rd 
day. 

Eruption consists, first of 
papules, then of vesi- 
cles, and on the eighth 
day of pustules. 

Eruption appears first up- 
on the forehead and 
about the mouih. 

Eruption lasts from 9 to 

12 days. 
Skin emits a sickly odor. 

Bronchitis and coryza 

rare. 
Slight sore throat and dry 

cough. 
Eruption seen on the 

back of the pharynx. 

Furred tongue with red 

edges. 
Temperature, 104° to 

106°. 
Fever greatly relieved by 

the eruption. 
Secondary fever always 

present. 
Pulse, 100 to 120 or 140. 

Cerebral symptoms, espe- 
cially convulsions in 
children, frequent. 

Desquamation in scabs, 
crusts and thick scales. 

Pneumonia an infrequent 
complication. 

Sequels; glandular en- 
largements, chronic 
diarrhea, and diseases 
of the eye. 

Vaccination protects. 



424 LECTUEES ON EEVEES. 

Roseola differs from scarlet fever in the size of its papules, 
which are larger and more raised than the red points of the 
latter disease. The intervening skin between the points soon 
becomes injected in scarlet fever, while in roseola it usually re- 
mains natural. Roseola is not, scarlet fever is, contagious. 

The distinctive symptoms of scarlet fever' and german measles 
are arranged in tabular form upon page 402. 

Erysipelas can hardly be mistaken for scarlet fever, if it is 
remembered that the redness gradually extends from one point, 
appears smooth and shining, and is usually accompanied by 
marked oedema of the connective tissue. 

Diphtheria is distinguished from scarlet fever by the usual 
absence of the eruption, the brick-dust-like flush of the throat, 
and the strawberry tongue. The exudation which occurs upon 
the tonsils and pharynx in diphtheria, is usually of a dirty gray 
or yellowish color, resembling wetted chamois leather, while that 
which takes place in scarlet fever is generally whitish or ash- 
colored. The urine in diphtheria though frequently albuminous, 
as in scarlet fever, never contains plax scindens. 

Prognosis. — The prognosis in scarlet fever is always uncer- 
tain at least, until after the first twenty-four hours of the erup- 
tion. It is largely influenced by the type of the prevailing epi- 
demic, the character of the attack, the vigor and age of the 
patient, and the presence or absence of serious complications. 

Favorable symptoms are: a fully and regularly developed 
rash of a bright red color, mild cerebral and throat symptoms, 
a pulse not exceeding one hundred and twenty beats per minute, 
and a temperature below 104° Fahr. 

Unfavorable symptoms are: early convulsive symptoms, pro- 
longed delirium or coma, persistent and long continued vomit- 
ing, colliquative diarrhea, a badly-developed and dark-colored or 
hemorrhagic eruption, early and ulcerative throat lesions, severe 
scarlatinal coryza, a very rapid pulse, a temperature above 105° 
Fahr., a dry, brown tongue, a disposition to a typhoid state, and 
the occurrence of any of the more serious complications. 

The rate of mortality, which is inversely proportionate to 
the age of the patient, varies from five to twenty per cent. 



LECTURE XXX. 
Scarlet Fever.— ( Continued. ) 

Treatment. 

Prophylaxis. — "Whenever scarlet fever appears in a family, 
the patient should be immediately isolated* in an upper room 
if possible. The apartment should be large, well lighted, and 
well rod Hated, and the temperature should be maintained at 6o° 
to 70°. Carpets, hangings, and all unnecessary articles of furni- 
ture should be removed from the room. Sheets should be hung- 
up in the door and window ways, and kept constantly saturated 
with Piatt's chlorides or some disinfecting solution. The bed 
and body linen should be changed daily, and immediately disin- 
fected or baked. The discharges from the bowels and kidneys 
should be received into vessels charged with disinfectants. 
Piatt's chlorides should be sprinkled on the bed and about the 
room. Inunctions with mildly carbolized vaseline, practiced 
several times daily, by preventing the dissemination of the dusty 
particles of the epidermis during desquamation, exert a marked 
prophylactic influence. Nurses, and attendants upon the sick, 
should not mingle with the healthy members of the family until 
desquamation is completed. Physicians should take a long ride 
in the open air after leaving the sick-room of a scarlatinous pa- 
tient, before visiting in houses where there are unprotected 
children. 

After recovery or death, the apartment should be thoroughly 

* All cases of scarlet fever occurring in the county, must be reported to the 
County Clerk; or, in cities, to the City Board of Health. 

(425) 



4^t> LECTUKES ON FEVERS. 

disinfected by the burning of sulphur, or by pouring crude car- 
bolic acid on chloride of lime, or by placing ozonizing powders 
— composed of equal parts of oxalic acid, peroxide of manganese 
and potassium permanganate — moistened with water, in dishes 
throughout the room. The bed and body linen, and all blankets 
and flannels that have been about the bed, should be immersed 
in some disinfecting solution and then thoroughly boiled or 
baked. The mattrass, pillows and curtains, and the clothing 
worn by nurses, should be exposed to a high temperature (240° 
or 250° ), and afterwards well aired before being used. After 
everything has been disinfected, the woodwork of the room 
should be thoroughly cleaned with carbolized water, the walls 
whitewashed, and the apartment freely aired for at least two or 
three days. 

It is believed that belladonna, administered morning and even- 
ing, will either prevent the disease, or cause it to run a milder 
course. The sidplio-carbolate of soda is also recommended for 
the same purpose. 

Principal Eemedies. — The remedies oftenest indicated in the 
premonitory stage are: aconite and belladonna in mild cases; 
veratrum viride, belladonna, solanum, apis, ailanthus, arum, am- 
monium carb. and rhus in severe cases; and arsenicum, ailan- 
thus, lachesis, ammonium carb. and camphor in malignant cases. 

During the eruptive stage the main remedies are: belladonna 
and rhus in mild cases; apis, solanum, mere, bi-jod, rhus tox., 
arsenicum iodide, ailanthus, hyoscyamus, veratrum viride and 
bryonia in severe cases; and arsenicum, ammonium carb., la- 
chesis and ailanthus in malignant cases. 

In the desquamative stage the principal remedies are: sul- 
phur, arsenicum and kali sulph. in mild cases;- and sulphur, 
hepar sulph., helleborus, squills, terebinthina, rhus, asclepias 
syr., apis, arsenicum, baryta carb.. calcarea carb., kali bich., sili- 
cea and arum, in severe cases. 

Belladonna is the principal remedy in the simpler forms of 
the fever, especially when the eruption is smooth, and is accom- 
panied by pain in the head and soreness of the throat. It is 
usually given in alternation with aconite, gelsemium or veratrum 
viride. Solanum may be used instead of belladonna when the 
spots are large, red and livid, and when there is a tendency to 
convulsions, especially in teething children. Veratrum viride 



PRINCIPAL REMEDIES. 427 

is called for when the fever is intense, the pulse very rapid, and 
there is great danger of cerebral congestion. Bryonia is indi- 
cated if the fever sets in with an adynamic type, and especially 
if, in consequence of exposure to the fresh air, the eruption re- 
cedes after it is fairly out. 

Apis will be of service when there is rapid swelling of the 
throat with sharp stinging pains, when the rash is interspersed 
with a miliary eruption, when with suppression of eruption 
there is entire suppression of urine, or when dropsy sets in with 
swelling of the genitals. Ailanihus is indispensable when the 
eruption assumes a livid hue, when the fever is intense and the 
heat pungent, and when there is a foetid discharge from the nos- 
trils accompanied by cracking at the corners of the mouth. It 
is adapted to malignant cases, and such as show extreme torpor. 
Arum is specially valuable in severe cases when the nose and 
mouth are sore, when the discharge from the nose is acrid and 
excortiating, when the lips commence to swell, and when the 
patient begins to pick the ringers and lips. Arsenicum iodide 
should be thought of when the discharges are irritating and 
corrosive, and there is swelling of the lymphatic glands, espe- 
cially in scrofulous individuals. Arsenicum cdb. is useful in 
malignant cases, when there is a tendency to prostration of the 
vital pow r ers. Ammonium carb. may be needed when the erup- 
tion is faintly developed, when the tonsils are enlarged, livid, 
and more or less covered with an offensive, sticky exudation, and 
when the parotid gland, especially the right, is inflamed and 
swollen. Rhus tox. may be administered early, instead of bry- 
onia, when torpor threatens, the glands become swollen, the are- 
olar tissue becomes implicated, rheumatic pains appear, and 
petechia are formed. Red iodide of mercury is always indicated 
for ulceration with swelling of the glands of the throat, and for 
swelling and inflammation of the cervical glands. Laches is is a 
remedy of the first importance when malignant throat symptoms 
appear, or when, during the decline of the eruption, the disease 
assumes a typhoid tendency. Hepar sidph. is especially valua- 
ble when suppuration threatens. 

Delirium is generally met by either belladonna, hyoscyamus 
or stramonium. Extreme restlessness and irritability call for 
coffea. Marked sopor with loud, slow respiration, indicates 
opium. When the eruption is suppressed or recedes, either 



428 LECTURES ON FEVERS. 

apis, bryonia, ailanthus, ipecac, cuprum or opium will be needed. 
Convulsions before the appearance of the eruption are met by 
belladonna, monotropa, cuprum, hyoscyamus and vercdrum vi- 
ride. Convulsions during the stage of desquamation call for 
moschus, vercdrum viride or cuprum. Cases that take on a ty- 
phoid tendency are usually met by arnica, baptisia or rhus. 
When diphtheria sets in, kali bich. and the red iodide of mercury 
do excellent service. 

Tartar emet. or kali bich. may prove serviceable when the 
larynx and trachea are involved, and there is great difficulty in 
breathing. Ipecac should be thought of if the chest is seriously 
affected, or if nausea and vomiting are leading symptoms. Spon- 
gia or bromine will be of service for the laryngitis. Tartar 
emet for pericarditis. Mercurius, bryonia or rhus for pleuritis. 
Arnica, rhus or salicylic acid for articular rheumatism. Arsen- 
icum, phosphorus or rhus if petechiee and ecchymoses appear. 
Arsenicum or veratrum cdb. for diarrhea. Mercurius cor. for 
bloody stools. Camphor when symptoms of collapse occur in 
malignant cases. 

Helleborus is the principal remedy for anasarca, and for 
threatened hydrocephalus. Apis, arsenicum, benzoate of lithia, 
cantharis, digitalis, helleborus, asclepias syr., squills and tere- 
binthina are of tenest indicated in post-scarlatinal dropsy. He- 
par sidph. will exert a favorable influence upon the tendency to 
dropsy if given as soon as there are traces of albumen in the 
urine. 

Muriatic acid or aurum mur. will be needed when the nose is 
sore and bleeds frequently. Rhus or mercurius nit. for phlyc- 
tenular conjunctivitis, suppurative choroiditis or panophthalmi- 
tis. Gelsemium for serous choroiditis. Aurum or kali jod. for 
plastic choroiditis. Mercurius cor. or arsenicum for ulcerative 
changes. Mercurius cor. or plumbum for albuminuric retinitis, 
Calcarea carb., carbo veg. or tellurium in external otitis. Psor- 
icum when there is a thin foetid discharge from the meatus. 
Terebinthina, hepar, silicea, nitric acid, aurum mur. or calcarea 
phos. in suppurative inflammation of the middle ear. Elaps in 
chronic suppuration of the middle ear accompanied with naso- 
pharyngeal catarrh. Muriatic acid or silicea for otorrhcea and 
deafness. 

Sulphur, arsenicum or kali sulph. maybe administered during 



LEADING INDICATIONS, 429 

the stage of desquamation to hasten the process and prevent 
sequels. Baryta, sulphur or iodide of calcarea should be thought 
of when induration of the cervical glands remains as a sequel. 

Leading Indications. — The guiding symptoms for the differ- 
ent remedies may be compiled as follows : 

Aconite. — Great dry heat and congestion of the skin. Fine 
prickling, as from needles, here and there. Rapid and full pulse 
with great restlessness and hurried respiration. Pain in the 
stomach with nausea and vomiting. Fear of being left alone. 
Anxious, frightened expression of the face. Redness of the soft 
palate and uvula (bell). In plethoric persons. 

Ailanthns. — General prostration, marked cerebral symptoms. 
Constant muttering delirium with sleeplessness and restlessness 
(hyos.). Intolerance of light. Hot, dry, harsh skin. Violent, 
vomiting, with dry, parched tongue (ars.). The teeth are cov- 
ered with sordes (baph, hyos.). Livid eruption, more profuse 
on the forehead and face. Small, weak, rapid pulse. Conges- 
tion of the throat, the mucous membrane is dark colored, almost 
livid. Angry-looking ulcers in the throat, with fetid discharge. 
The glands of the neck are swollen and sensitive. Thin, watery, 
offensive diarrhea. Petechia. In malignant cases. 

Ammonium, carb. — Burning in the throat, down to the ceso^ 
phagus (canfh.). Putrid sore throat; gangrenous ulceration on 
the tonsils (mur. acid). Hard swelling of the right parotid and 
cervical lymphatic glands. Tonsils enlarged and livid, and cov- 
ered with a sticky, offensive exudation. Faintly developed erup- 
tion. Stertorous breathing; threatened paralysis of the brain, 
with excessive vomiting (zincum). Involuntary evacuations. 

Apis mel. — High fever with chilliness from the slightest mo- 
tion. Dull pain over the whole head relieved by pressure. So- 
por with shrill, piercing shrieks. Great restlessness and nervous 
agitation. Tongue of a deep red color and covered with blisters 
(rhus). Dryness of the tongue, mouth and throat. Swelling 
and ulceration of the tonsils and palate (mere.). Stinging, 
smarting pain in the throat with difficulty in swallowing. Burn- 
ing, pricking, smarting, itching sensations in the skin. Intensely 
deep red rash (bell). Great soreness in the pit of the stomach 
when touched (bry.). Frequent, foul, involuntary, slimy and 



430 LECTURES ON FEVERS. 

bloody stools. Dyspnoea with great restlessness and trembling 
(ars.). Suppression of urine (hyos., opium); albuminuria (phos. 
acid). Dropsical symptoms during desquamation. 

Arsenicum. — Suppression or delay of the eruption with ap- 
pearance of petechia. Great restlessness and extreme prostra- 
tion. Yomiting and diarrhea. Dryness in the mouth with thirst 
for frequent sips of water (bell., opp. bry.). Dry, brown, cracked 
tongue (rhus). Dryness and burning in the fauces and throat 
(bell, lack.). Grinding of the teeth while asleep (hell.). Par- 
oxysmal pains in the ears; profuse, thin, acrid discharge from 
the middle ear. Difficult breathing with great anguish. Urine 
dark colored and bloody, and passed with difficulty. Involun- 
tary micturition (hyos.) Pulse frequent, hard and tense, or 
small, trembling and intermittent. Puffiness of the eyelids; 
cedematous swelling of the feet. Typhoid symptoms. 

Arum. — Ichorous discharge 'from the nose, excoriating the 
nostrils and upper lip (oj's. iocl, mere. cor.). Soreness and 
ulceration of the mouth and fauces. Tongue red and sore with 
elevated papillae. Swelling of the sub-maxillary glands. Scar- 
let eruption all over the body, with much itching and restless- 
ness. Picking at the nose, lips and finger-nails. Spasmodic 
night cough ( hyos. ) 

Aurum in ur. — Obstinate foetid otorrhcea. Foetid mucus dis- 
charge from the nose. Caries of the nasal bones (cole, curb.)- 
Painful swelling of the sub-maxillary glands. 

Baptisia. — Great prostration with nervous restlessness, espe- 
cially at night. Dull, stupefying headache (gels.). Nausea 
followed by vomiting. The eruption is more marked in the 
throat than upon the skin. Dark, putrid ulcers in the throat 
with difficult deglutition. Swelling of the parotid glands. Pu- 
trid, offensive breath with profuse salivation (mere). Tongue 
covered with a yellowish-brown coating in the center, but red 
and shining at the edges. Typhoid symptoms. 

Baryta carl). — Eight parotid swollen and painful. Inflam- 
mation of the tonsils with tendency to suppuration (hepar). 
Chronic induration of the tonsils (cede. carb.). Swelling of the 
sub-maxillary glands (mere). Ailments during and after des- 
quamation. Adapted to scrofulous children. 



LEADING INDICATIONS, 431 

Belladonna. — High fever and sore throat. Severe head symp- 
toms with delirium. The head is hotter than other parts of the 
body (am.). Drowsiness broken by starts and frightened out- 
cries. Convulsive motions of the limbs. Smooth, scarlet-red 
eruption upon the skin. The skin is so hot that it imparts a 
burning sensation to the hand. Great dryness of the fauces and 
throat. Inflammation of the fauces and pharynx, with dark 
redness of the mucous membrane, and burning, stinging pains 
(apis). Face fiery red, or else pale, puffy and sunken. Tongue 
white in the center with red edges (gels.), or red all over with 
raised papillae. Difficult deglutition; fluids swallowed return 
through the nose (kali bich.). Stomach and abdomen sensitive 
to the touch (bry.). Swelling of the neck, extremely painful to 
the touch and motion. 

Bromine. — Swelling and induration of the sub-maxillary and 
left parotid glands (conium). Diphtheritic complications. 

Bryonia. — Exceedingly irritable, everything makes him angry 
(cliam.). Sensation as if sinking deep down in bed. Headache 
as if everything would press out of the forehead, worse on mo, 
tion (bell.). Stitches in the throat when swallowing (bell.). 
Dry, parched lips. Delay or sudden retrocession of the erup- 
tion (ipecac). Sensation of weight upon the chest with trouble- 
some cough. Symptoms of pleuritis or meningitis (hell.). Drop- 
sical symptoms. Constipation. 

Calcarea carb. — Sore throat with difficult deglutition. Swell- 
ing and induration of the glands of the neck (baryta, mere). 
Aphthae on the tonsils and roof of the mouth. Accumulation of 
mucus in the air passages. Purulent discharge from the ears 
(liepar, mere). Swelling and redness of the lids, with nightly 
agglutination (sulpli.). Ulceration of the nostrils. In scrofu- 
lous subjects. 

Camphor.— Sudden retrocession of eruption with coldness of 
the skin, and great prostration (cuprum). Suffocative dyspnoea. 
Accumulation of mucus in the air passages (ipecac). Great 
precordial anxiety. Weak, scarcely perceptible pulse (carbo 
vecj.). Cold, clammy sweat (verat. alb.). Suppression of urine. 

Capsicum. — Burning and smarting in the throat, worse be- 
tween the acts of deglutition. Burning vesicles on the tongue 
and mouth. Shivering and chilliness after drinking (ars.). 



432 LECTURES ON FEVERS. 

Painful swelling behind the ear. Caries of the mastoid pro- 
cess. Exalted sensibility of all the senses (coffea). 

Carbolic acid. — Dusky red face, with a white circle around 
the mouth. Lips and tongue dry and covered with sordes. 
Fauces fiery red and swollen. Ulcerated patches on the lips and 
cheeks. Extremely foetid breath (bapt). Liquids on being 
swallowed return through the nose. Weak or thready pulse. 
Excessive prostration with dizziness and headache. Eruption of 
a dark red color. Miliary vesicles all over the body. Urine 
light-colored and scanty. Involuntary discharge of mucus from 
the anus when urinating. 

Carbo veg. — Restlessness and anxiety. Coldness of the breath 
and tongue (verat alb.). Excessive prostration (ars.). Inter- 
nal burning, wants to be fanned (ars.). Sticky, cold perspira- 
tion. Livid, purple appearance of eruption (lach.). Thread- 
like, scarcely perceptible pulse. Putrid sore throat. Ecchymoses. 

Colciiiciiiii. — Vomiting, excited or renewed by every motion 
(bry.). Senses too acute; over affected by strong odors. (Ede- 
matous swelling of the legs and feet (ars. ). Scanty discharge of 
bloody urine, looking almost like ink, and containing albumen- 
Rheumatic pains in the arms, extending into the fingers (bry., 
caul.). 

Coninm. — Swelling and induration of the parotid and sub- 
maxillary glands. In scrofulous individuals. 

Cuprum acet. — Excessive nausea; vomiting relieved by drink- 
ing cold water (bry.). Convulsions precede the appearance, and 
follow the sudden retrocession of the eruption. Cold, bluish 
face with blue lips (lach.). The patient is afraid of every one; 
clings tightly to the nurse. 

Digitalis. — Extreme debility with great anxiety (aco.). 
Thready, slow, intermittent pulse. Constant urging to urinate 
with scanty discharge. Dark, turbid urine. Nephritis after 
desquamation, with anasarca and oedema of the lungs. 

Gelsemium. — Intense fever with frequent, soft, weak pulse. 
Heat with languor and drowsiness. Muttering delirium during 
sleep. Crimson flush of the face with suffused eyes. Great 
nervous excitement. The throat feels swelled or filled up, and 



LEADING INDICATIONS. 433 

is diffusely red. Throbbing in the ears, pains shoot from the 
throat to the ears when swallowing. Great aversion to light, 
with dilatation of the pupils (bell.). Trembling and complete 
loss of muscular power, 

Helleborus. — Face pale and oedematous. Urine scanty and 
dark colored ; after settling it looks like coffee grounds. White, 
gelatinous stools with tenesmus. Sudden dropsical symptoms. 
In scrofulous children, and in children during dentition. 

Hepar sulph. — Stitches in the throat extending to the ear 
(gels., kali bich.); worse on swallowing. Swelling of the paro- 
tid and sub-maxillary glands. Early decrease of the urinary 
secretions with traces of albumen and casts. Discharge of fetid 
pus from the ears. Ulcers and specks on the cornea. 

Hyoscyamus. — Late appearance of the eruption, causing great 
nervous excitement. Constant desire to get out of bed. Red, 
sparkling, staring eyes (bell.). Constrictive sensations in the 
throat with inability to swallow (bell.). Clean, parched, dry 
tongue. Dark-red, "flushed face. Muscular twitchings (siram.). 
Subsultus tendinum. Involuntary evacuations. Retention of 
urine (opium). Grating of the teeth (apis, hell.). Brownish 
spots or gangrenous vesicles on the body. 

Ipecacuanha. — Constant nausea and vomiting of green bilious 
or slimy substance. Suppressed eruption. Violent itching of 
the skin. Dyspnoea. 

Kali bicli. — Throat purple, with small patches of tough, firmly 
adhering exudation all over the fauces. Pain extending to the 
right ear, when swallowing. Swelling of the parotid glands. 
Ulceration of the septum of the nose (aurum). Purulent in- 
flammation of the whole nasal mucous membrane (nit. acid), 
Diphtheria. 

Kali carb. — Inflammation and swelling of the right parotid 
gland. Mouth and tongue covered with painful burning vesicles 
(mere. cor.). Smell from the mouth like that of old cheese. 
Swelling between the eyebrows and upper lids like a little bag. 

Kali permaiigaii. — General and excessive prostration. Diph- 
theritic exudation all over the fauces. Extremely foetid breath. 
Great dyspnoea. 

Lac caninum. — Pricking or cutting pains when swallowing 



434 LECTURES ON FEVERS. 

extending up to the ears. White ulcers on the tonsils; pharyn- 
geal inflammation. Ulcers shine like silver gloss. Enlarged 
glands in scrofulous children. 

Laches is. — Great mental and physical exhaustion. Aggrava- 
tion of all the symptoms after sleep (apis). Stupor and mut- 
tering delirium (apis). The eruption appears slowly, or turns 
black or bluish. Dry, red or black, cracked and bleeding tongue 
(ars.). Hawking of mucus with dryness and rawness in the 
throat. The exudation commences on the left tonsil and spreads 
towards the right. External swelling of the neck and glands. 
External throat very sensitive to the touch. Black urine; watery, 
offensive stools (ars.). Passive hemorrhages of dark, fluid 
blood. Typhoid symptoms. 

Laclin ant lies. — Heat and burning in the skin with sensation 
as if the eruption would appear. Circumscribed redness of the 
cheeks (rlius). Dryness and roughness of the throat, with 
pricking pain when swallowing. Stiffness of the neck after 
scarlet fever. 

Lithium foenzoate. — In post-scarlatinal dropsy, when the 
urine is dark, brownish-red, has a pungent odor, and there are 
present swelling of the joints, rheumatic pains and cardiac symp- 
toms. Concretions in small joints. 

Lycopodium. — Inflammation of the throat of a brownish-red 
color, with stitches during deglutition. Ulceration of the ton- 
sils, beginning on the right and spreading to the left (opp. lack. ). 
Swelling and suppuration of the tonsils (hepar). Swelling and 
sensitiveness of the sub-rnaxillary and cervical glands. Urine 
scanty, with or without sandy sediment. Grinding of the teeth 
even when fully awake. Secondary eruptions of dark-red blotches 
on the hands, thighs, back and face. Falling out of the hair 
(graph., phos.). 

Merc cyanuret. — Excessive prostration. Marked redness of 
the fauces with difficulty of swallowing. Suppression of urine 
(apis). Engorgement of the parotid and sub-maxillary glands. 
Diphtheritic symptoms. 

Mercurius. — Aphthae in the mouth with profuse salivation. 
Ulcers upon the palate and tonsils, with ash-colored exudation. 
Dirty-yellow coating on the tongue. Swelling and inflammation 






LEADING INDICATIONS. 435 

of the glands of the neck. Foetid breath (bapt). Nasal bones 
swollen and sensitive to the touch (aurum). Otitis with bloody, 
offensive discharge {graph., puis.). Itching and restlessness, 
worse at night and after sweating. 

Merc. iocl. flavus. — Fauces bluish-red and ulcerated ( Jack. ) . 
Induration of the parotid and cervical glands and tonsils. 
(Edema of the neck and throat (apis). Sharp, throbbing, bor- 
ing pains in the left ear. Tongue yellow with tip and edges clean 
and red. Foetid discharge from the fauces and nares. Urine 
scant}- and high-colored. 

Merc. iod. ruber. — Livid, purplish patches in the throat. 
Exudation limited and easily detached; mostly on the left ton- 
sil. Hawking up white and tough mucus. Swelling of the 
glands. Profuse salivation with pressure in the throat on swal- 
lowing. Diphtheritic symptoms. 

Muriatic acid. — Marked redness all over the body, or else 
scanty eruption interspersed with petechias. The throat and 
fauces are dark-red and swollen, and covered with a grayish- 
white exudation. Excessive dryness of the lips, mouth and 
tongue. Acrid discharge from the nose, excoriating the nostrils 
and upper lip (arum, mere. cor.). Pulse rapid and very feeble, 
intermits every third beat (fourth beat, nit acid). Complete 
prostration of the vital forces. Constant inclination to slide 
down in bed. Typhoid symptoms. 

Nitric acid. — Soreness and swelling of the tonsils with diffi- 
cult deglutition. Dryness and intense burning in the mouth and 
fauces. Foetid odor from the mouth (bapt, mere). Profuse 
discharge of thin, purulent matter from the nostrils. Offensive, 
purulent discharge from the ear (sil). Swelling of the parotid 
and sub-maxillary glands (mere,). 

Opium. — Drowsiness or sopor. Complete loss of conscious- 
ness (hyos.) with slow, stertorous breathing. Stupid sleepless- 
ness with frightful visions. Bed feels hot, can hardly lie on it. 
Dryness of the throat with inability to swallow. Retention of 
urine. Picking at the bedclothes (hyos.). Impending cerebral 
paralysis . 

Phosphorus. — Constant sleepiness. Low muttering delirium 
(am., bapt, rhus). Contracted pupils (opium, physostigma). 



436 LECTURES ON FEVERS. 

Sudden disappearance of eruption with alarming chest symp- 
toms. Difficulty of hearing, especially of the human voice 
(silicea). Diy, immovable tongue, cracked and covered with 
sordes (ars., verat alb.). Thirst with desire for very cold drinks 
(rhus). Burning sensation, causing a constant change of posi- 
tion. (Edema of the lids and around the eyes (apis, rhus). 
Brown urine, depositing a brick-dust sediment (cinch., lye). 
Small, quick, easily compressed pulse. Ecchymoses. Falling 
off of the hair (graph., lye.) 

Phosphoric acid. — Perfect indifference (cinch., lye). Dry- 
ness of the mouth and throat (mix). Bleeding from the nose 
(ham., ledum). Meteoristic distension of the abdomen with 
rumbling and gurgling. Involuntary, whitish-gray stools. Fre- 
quent, small, feeble pulse. Bluish-red spots on the parts upon 
which the patient lies. Ecchymoses. 

Phytolacca. — Great prostration with violent pains in the 
head, back and extremities. Dryness of the throat with swell- 
ing of the tonsils (bell.). Dark red color of the fauces (bapt). 
Feeling as of a lump in the throat, and great pain at the root of 
the tongue when swallowing (bell., lack.). Thick, white and 
yellow exudation upon the fauces (kalibich.). Shooting pains 
through both ears when swallowing. Hardness of the glands in 
the right side of the neck: Rheumatic pains in the extremities. 
The eruption appears dry and shriveled; the skin feels dry and 
harsh, like brown paper. Diphtheritic symptoms. 

Rhus tox. — Great restlessness and uneasiness (ars.). Active 
delirium and great prostration. Dry, red, cracked tongue (bapt, 
bell). Redness of the tip of the tongue in the shape of a tri- 
angle. Dark red, livid eruption with increasing fever and great 
nocturnal restlessness. Ichorous discharge from the nostrils. 
Swelling and induration of the parotid and sub-maxillary glands. 
Great thirst for cold drinks (phos.), especially cold milk. In- 
voluntary foetid stools during sleep. Rheumatic pains in the 
limbs and joints. Itching over the whole body (sulphur). Ves- 
icular eruption with itching and burning. Typhoid symptoms. 

Secale. — Constant sighing. Great prostration and extreme 
restlessness. Mania with inclination to bite (bell., siram.). 
Aversion to being covered. Fear of death (ars.). Brown or 
blackish tongue (ars.). Violent, unquenchable thirst. Invol- 



LEADING INDICATIONS. 437 

untary diarrhea (hyos.). Suppression of urine. Bloody and 
albuminous urine (terebinth.). Extensive ecchymoses. 

Silicea. — Induration of glands from tardy convalescence. 
Swelling and suppuration of the parotid gland. Caries of the 
mastoid process. Otalgia with drawing, stitching pains (puis.). 
Itching in Eustachian tubes and ears, especially when swallow- 
ing. Great sensitiveness to cold air (sejria), takes cold easily. 
Disposition to boils. In scrofulous children. 

Stramonium. — Convulsions excited by touch, or from looking 
at bright, shining objects. Coppery-red eruption with heat, dry- 
ness and itching of the skin. Great dryness of the throat. Vio- 
lent thirst, especially for sour drinks (bry., secede). Yellowish- 
brown coating on the tongue, which is dry in the center (bapt.). 
Black stools which smell like carrion (ars., cai'bo. veg. ). Constant 
restlessness with jerking motions of the whole body. Suppres- 
sion of urine. 

Sulphur. — During the stage of desquamation, and in slowly 
progressing cases. In scrofulous children. 

Terebiiithina. — Headache with intense pressure and fullness 
of the head. Slowly appearing eruption. Tongue red, smooth 
and glossy. Great drowsiness. Yomiting of mucus, bile or 
blood, aggravated by drinking. Burning and drawing from the 
right kidney to the hip. Urine smoky and turbid, depositing a 
sediment like coffee grounds. Albuminuria and hasrnaturia. 
Strangury (canth.). Intestinal catarrh and diarrhea. Anasarca 
(hell). Ascites (apocynum can.). 

Yeratrum vir. — Muttering delirium. Bestless sleep with 
dreams of being drowned. Severe frontal headache with vomit- 
ing. Bed streaks in the middle of the tongue; yellow edges. 
Intense fever with flushed face and convulsive twitchings of the 
facial muscles. Sudden spasms with nausea and vomiting and 
great prostration. The child trembles as if frightened and on 
the verge of spasms. Convulsions precede the outbreak of the 
eruption. Irregular, hard, frequent pulse. Oppression of the 
chest with slow, labored breathing. Dark, turbid, foetid urine. 
Bheumatism. 

Zincum. — Retrocession of the eruption (cuprum). Threat- 
ened paralysis of the brain. Twitching of the hands and feet. 



438 LECTURES ON FEVERS. 

Dryness of the throat with accumulation of mucus in the pos- 
terior nares. Small, filiform pulse. Involuntary evacuations. 

HYGIENIC AND DIETETIC TREATMENT. 

The sick room should be large and well ventilated, and the 
temperature should be kept between 65° Fahr. and 70° Fahr. 
Ail superfluous articles of furniture and everything that is liable 
to absorb and retain contagion should be removed from the 
apartment. Throughout the whole course of the disease quiet- 
ude and the strictest cleanliness should be observed. The bed 
and room should be sprinkled with Piatt's chlorides, diluted one 
part to ten, or some other disinfectant. Sheets saturated with 
some disinfecting solution should be hung up in the door and 
window ways of the apartment. The bed and body linen should 
be changed daily, and immediately thrown into a vessel contain- 
ing a solution of carbolic acid, before being removed from the 
room. The discharges from the bowels or kidneys should be 
received into vessels charged with disinfectants, and immedi- 
ately disposed of. 

Cool or cold drinks in small amounts and at short intervals are 
beneficial as well as grateful to the patient. Pieces of ice held 
in the mouth afford the most marked relief when throat compli- 
cations are severe. The diet should, as a rule, be liquid, and 
may consist of milk, milk and lime water, beef tea (p. 193), but- 
termilk, koumyss, clam broth, light soups, or farinaceous food. 
If exhaustion is great, brandy with milk (p. 306), beef or chicken 
tea and wine whey (p. 194) may be given. When diphtheria 
occurs as a complication, brandy or whisky, should be admin- 
istered in teaspoonful doses every hour or two, or until the sys- 
tem becomes saturated. 

The local treatment of the throat consists in the early appli- 
cation of a cold water compress to the front of the neck from 
ear to ear. When there is considerable infiltration of the throat, 
hot applications externally and steam inhalations, warm gargles, 
or sprays internally are of the greatest benefit. If exudation 
occurs, carbolized lime water spray (cold) — carbolic acid three 
drops, lime water one ounce — used three or four times in twenty- 
four hours, for three or four minutes at a time, is exceedingly 
efficacious. Yiscous secretions which collect in the fauces should 
be removed with a camel's hair brush. When diphtheria and- 



HYGIENIC AND DIETETIC TREATMENT. 439 

scarlet fever are combined, a solution of potassium permanganate 
or of liquor potassse and lime water — one -half of a drachm to 
four ounces — administered in the form of spray by the atomizer, 
should be used. When there is enormous swelling of the glands 
below and behind the angle of the jaw, or when coryza is pres- 
ent, the nasal passages should be cleansed by means of a camel's 
hair brush, or by the injection of a mildly carbolized wash, and 
then freely anointed. When there is much purulent discharge 
from the meatus, frequent syringing with warm water should be 
employed. When suppuration of the external glands or tissues 
about the neck cannot be prevented, hot fomentations should be 
resorted to, and the abscesses opened early. 

When in the early part of the disease the temperature runs up 
to 104° Fahr., the external use of cool or tepid water should 
be resorted to. The water may be employed either by immer- 
sion in a bath ten degrees below that of the patient, by wrapping 
the patient in a sheet wrung out in water at a temperature of 70 D 
Fahr., or by sponging the surface with cold or tepid water. 
Cloths wrung out of water at a temperature of 85° Fahr. or 90° 
Fahr., applied to the surface, and changed every hour or two, 
are frequently used instead of either the full bath or the pack. 
As in typhus fever, when the full bath is used the patient must 
be kept in the bath until his temperature falls to 101° Fahr., 
then taken out, quickly dried and placed in bed. As soon as the 
temperature rises to 104° Fahr. the patient must receive another 
bath. The best results, however, are generally obtained from 
either the icei sheet, the sponging or the application of wet cloths. 

When there is much itching and burning of the skin, the sur- 
face should be gently anointed with mildly carbolized vaseline. 
During desquamation, night and morning inunctions preceded 
by warm baths, are highly beneficial. 

When the kidneys are involved, large, hot poultices prove effi- 
cacious. Daily microscopical and chemical examination of the 
urine should be instituted. If oedema occurs, the patient should 
be given a hot bath or a moist warm pack for at least two hours, 
then removed to a warm room with the temperature at 72° Fahr. 
or 75° Fahr., and kept in bed with sufficient covering to induce 
constant, gentle perspiration. Should the oedema become ex- 



440 LECTURES ON FEVERS. 

cessive, small punctures may be made in the lower part of the 
legs to favor the removal of the fluid. 

All exposure to cold should be carefully avoided, and the pa- 
tient should not be allowed to leave his room for three or four 
weeks at least from the beginning of the attack. 

During convalescence, warm clothing should be worn. 



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Allen, De. T. F. Encyclopoedk of Pure Materia Meclica. 

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BiEHR, Dr. Bernhard. The Science of Therapeutics, accord- 
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Bartlet, Dr. Elisha. The History, Diagnosis and Treatment 
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Bartholow, Dr. Roberts. A Manual of Hypodermatic Med- 
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Bartholow, Dr. Roberts. A Treatise on the Practice of Med- 
icine. 1883. 

Bayes, Dr. William. Typhoid Fever, and Use of Baptisia 
Tinctoria. London. 1872. 

Bennet, Dr. J. Hughes. Clinical Lectures on the Principles 
and Practice of Medicine. New York. 1872. 

Blackley, Dr. Charles H. Hay Fever; its Causes and 
Treatment. London. 1880. 

Botkin, M. S. De la Fievre. Paris. 1872. 

Bristowe, Dr. John S. A Treatise on the Theory and Prac- 
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Burt, Dr. W. H. Physiological Materia Medica. Chicago. 
1883. 

Budd, Dr. William. Typhoid Fever; its Nature, Mode of 
Spreading, and Prevention. London. 1874. 

Carter, Dr. H. Vandyke. Spirillum Fever. London. 1882. 

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442 LECTUKES ON FEVERS. 

Cowperthwaite. A. 0. Elementary Text Book of Materia 

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Cohn, Dr. Ferdinand. Bacteria. Translation. 1881. 

Castan, M. A. Traite Elementaire des Fievres. Paris. 1872. 

Day, Dr. William H. Diseases of Children. Philadelphia. 
1881. 

Dobbell, Dr. Horace. Reports on the Progress of Practical 
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Dolan, Dr. Thomas M. Vaccination; its Place and Power. 
London 1883. 

Dowell, Dr. On Yellow Fever. Philadelphia. 1876. 

Drury, Dr. William V. Eruptive Fevers. London. 1877. 

Duncan, Dr. T, C. A Text Book on the Diseases of Infants 
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Edmonds, Dr. W. A. A Treatise on Diseases peculiar to In- 
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Edwards, Dr. JosepIi F. Vaccination; arguments pro and 
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Flint, Dr. Austin. A Treatise on the Principles and Prac- 
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Gregory, Dr. George. Lectures on the Eruptive Fevers 
New York. 1851. 

Gresinger, Wilhelm. Traite des Maladies Infectieuses.. 
Paris. 1868. 

Hale, Dr. Edwin M. Materia Medica and Special Therapeu- 
tics of the New Remedies. Philadelphia. 1880. 

Hall, Dr. F. de Haviland. Differential Diagnosis. Phila- 
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Hardaway, Dr. W. A. Essentials of Vaccination. Chicago. 
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Hartshorne, Dr. Henry. Essentials of the Principles and 
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Hempel, and Arndt. Materia Medica and Therapeutics. 

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Holcombe, Dr. W. H. Yellow Fever and its Homoeopathic 
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Hudson, Dr. A. Lectures on the Study of Fever. Philadel- 
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Jousset. Lectures on Clinical Medicine. Translation. 

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Klebs and Tommassi-Crudelli. Studies on the Cause of In- 
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La Koche, Dr. B. Remarks on the Origin and Mode of Yel- 
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INDEX. 



Abortive typhoid fever, 147. 
Abscesses, in relapsing fever, 314. 

in typhoid fever, 150. 

in yellow fever, 202. 
Age, in etiology of cerebro-spinal 
fever, 224. 

in etiology of typhoid fever, 138. 

of person to be vaccinated, 366. 
Ague, 48 
Albuminuria, in scarlet fever, 419. 

in typhoid fever, 158. 
Algid, variety of pernicious fever, 92. 
Alcohol, excess of, in etiology of ty- 
phoid fever, 169. 
America, invaded by scarlet fever- 
404. 

by small-pox, 332. 
Anaemia, after relapsing fever, 315. 
Analysis of chart, of cerebro-spinal 
fever, 227. 

of dengue, 106. 

of hay fever, 128. 

of influenza, 256. 

of measles, 383. 

of pernicious fever, 93. 

of relapsing fever, 315. 

of scarlet fever, 414. 

of simple continued fever, 31. 

of simple intermittent fever, 53. 

of simple remittent fever, 80. 

of small-pox, 341. 

of typhoid fever, 148. 

of typho-malarial fever, 115. 

of typhus fever, 281 . 

of yellow fever, 203. 
Anasarca, in scarlet fever, 411. 



Apyretic intervals, in simple inter- 
mittent fever, 51. 

in relapsing fever, 313. 
Arachnoid, condition of, in cerebro- 
spinal fever, 234. 
Arthritic pains in relapsing fever r 
315. 

in dengue, 105. 
Asthma, hay, clinical history of, 

125. 
Bacillus malaria?, 18, 39. 
Bacteria, description of, 16. 

definition of, 16. 

effects of boracic acid upon, 20. 

effects of carbolic acid upon, 20. 

effects of ozone upon, 20. 

forms of, 16. 

in pneumonia, 23. 

in ulcerative endocarditis, 23. 

reproduction of, 18. 

where found, 20. 
Bacterium, the weight of a, 21. 
Bedsores, in typhoid fever, 157. 

in typhus fever, 281. 
Beef essence, formula for, 190. 
Beef tea, formula for, 193. 
Bibliography, 441. 
Bilious remittent fever, 80. 
Black vomit, in yellow fever, 207. 
Blood, changes in, in cerebro-spinal 
fever, 233. 

in chronic malarial infection, 101. 

in measles, 389. 

in miliary fever, 376. 

in pernicious fever, 96. 

in relapsing fever, 321. 



(M5) 



446 



INDEX 



in scarlet fever, 421. 

in simple intermittent fever, 55. 

in simple remittent fever, 82. 

in typhoid fever, 162. 

in typho-malarjal fever, 117. 

in typhus fever, 289. 

in yellow fever, 209. 
Boils, in typhoid fever, 157. 

in typhus fever, 281. 
Boracic acid, action of, upon bacte- 
ria, 20. 
Bovine virus, points and slips for, 

366. 
Bowels, hemorrhage from, in typhoid 
fever, 151. 

in yellow fever, 205. 
Brain, changes in, in cerebro-spinal 
fever, 234. 

in typhoid fever, 163. 

in typhus fever, 290. 

in yellow fever, 209. 
Bronchitis, in influenza, 258. 

in typhus fever, 288. 
Bronzed liver, in simple remittent 

fever, 83. 
Caecum, lesions of,iD relapsing fever, 
321. 

in typhoid fever, 164, 
Catarrh, bronchial, in influenza, 255. 

in typhoid fever, 156. 
Catheterism, in typhoid fever, 158. 
Carbolic acid, action Of, upon bacte- 
ria, 20. 
Carbon, how obtained, by bacteria, 

20. 
Cerebro-spinal fever, chart of, 228. 

clinical history of, 226. 

complications of, 233. 

definition of, 223. 

differential diagnosis of, 235. 

etiology of, 224. 

history of, 223. 

morbid anatomy of, 233. 

prognosis of, 237. 

schizomycetes in, 23. 

synonyms of, 223. 

treatment of, 239. 

varieties of, 225. 
Chart of, cerebro-spinal fever, 228. 



of chicken pox, 373. 

of dengue, 107. 

of german measles, 401. 

of influenza, 257. 

of hay fever, 128. 

of measles, 385. 

of miliary fever, 377. 

of pernicious fever, 94. 

of relapsing fever, 316 

of scarlet fever, 415. 

of simple continued fever, 32. 

of simple intermittent fever, 53. 

of simple remittent fever, 81. 

of small-pox, 342. 

of typhoid fever, 149. 

of typho-malarial fever, 116. 

of typhus fever 282. 

of varioloid, 369. 

of yellow fever, 204. 
Chart, temperature, of simple con- 
tinued fever, 33, 34. 

of relapsing fever, 319. 

of typhoid fever, 153, 155, 161. 

of typhus fever, 285. 

of yellow fever, 207. 
Cheyne-Stokes respiration in cere- 
bro-spinal fever, 226. 
Choleraic variety of pernicious fever, 

92. 
Choriditis after relapsing fever, 315. 
Chicken-pox, chart of, 373. 

clinical history of, 371. 

definition of, 371. 

differential diagnosis of, 372. 

duration of, 372. 

etiology of, 371. 

history of, 371 

incubation of, 371. 

prognosis of, 372. 

synonyms of, 371. 

treatment of, 372. 
Chronic malarial infection, definition 
of, 100. 

clinical h story of, 100. 

differential diagnosis of, 102. 

etiology of, 100. 

morbid anatomy of, 101. 

prognosis of, 102. 

synonyms of, 100. 



INDEX. 



447 



treatment of, 102. 
Classification, of bacteria, 17. 

of fevers, 27. 
Climate, in etiology of cerebro-spinal 
fever, 224. 

of typhoid fever, 137. 

of typhus fever. 274. 
Clinical history , of cerebro-spinal fe- 
ver, 226. 

of chicken-pox, 371. 

of chronic malarial infection, 100. 

of cow-pox, 360. 

of dengue, 104. 

of german measles, 400. 

of influenza, 255, 

of inoculation, 364. 

of hay fever, 125. 

of measles, 381. 

of miliary fever, 375. 

of pernicious fever, 90. 

of relapsing fever, 312. 

of scarlet fever, 407. 

of simple continued fever, 29. 

of simple intermittent fever, 49. 

of simple remittent fever, 77. 

of small-pox, 336. 

of typhoid fever, 142. 

of typho-malarial fever, 112. 

of typhus fever, 276. 

of vaccinia, 361. 

of varioloid, 368. 

of yellow fever, 200. 
Cold applications, in scarlet fever, 
438. 

in typhoid fever, 191. 

in typhus fever, 305. 
Colliquative variety of pernicious fe- 
ver, 93. 
Coma, in cerebro-spinal fever, 229. 
Coma vigil, in typhus fever, 283. 
Comatose variety of pernicious fe- 
ver, 90. 
Confluent small-pox, 339, 
Constipation in typhus, 289, 
Contagion, definition of, 28. 

in measles, 380. 

in relapsing fever, 310. 

in scarlet fever, 405. 

in small-pox, 334. 



in typhoid fever, 140. 

in typhus fever, 274. 

in yellow fever, 197. 
Contagium vivum, 16. 
Contagious fevers, definition of, 28. 
Convulsions, in cerebro-spinal fever, 
229. 

in pernicious fever, 93. 

in scarlet fever, 416. 

in typhoid fever, 159. 

in typhus fever, 284. 
Cornea, ulceration of, in scarlet fe- 
ver, 420. 

in small-pox, 341. 
Cough, in influenza, 258. 

in measles, 386. 

in typhoid fever, 156. 
Countenance, in influenza, 255. 

in small-pox, 338. 

in typhoid fever, 143. 

in typhus fever, 276. 

in yellow fever, 200. 
Cow-pox, clinical history of, 360 

definition of, 360. 

etiology of, 360. 

history of, 360. 

synonyms, 360. 
Coze and Feltz, experiments of, upon 

bacteria, 22. 
Critical days, 44. 
Crisis in typhus fever, 286. 
Cutaneous lesions, in cerebro-spinal 
fever, 231. 

in chicken-pox, 371. 

in measles, 387. 

in miliary fever, 376. 

in scarlet fever, 418. 

in small-pox, 343. 

in typhoid fever, 157. 

in typhus fever, 287. 

in varioloid, 368. 

in yellow fever, 203. 
Cystitis in typhoid fever, 158. 
Deafness, after cerebro-spinal fever. 
233. 

after scarlet fever, 413. 

in typhoid fever, 159. 

in typhus fever, 284. 
Death-point of bacteria, 18. 



us 



INDEX. 



Definition, of bacteria, 16. 

of cerebro-spinal fever, 223. 

of chicken-pox, 371. 

of chronic malarial infection, 100. 

of cow-pox, 360. 

of dengue, 103. 

of german measles, 399. 

of hay fever, 123. 

of inoculation, 364. 

of influenza, 253. 

of measles, 379. 

of miliary fever, 374. 

of pernicious fever, 89. 

of relapsing fever, 307. 

of scarlet fever, 404. 

of simple continued fever, 29. 

of simple intermittent fever, 48. 

of simple remittent fever, 76= 

of small-pox, 331. 

of typhoid fever, 136. 

of typho-malarial fever, 111. 

of typhus fever, 272. 

of vaccinia, 361. 

of vaccination, 365. 

of varioloid, 368. 

of yellow fever, 195. 
Deglutition, difficult, in scarlet fe- 
ver, 417. 

in typhoid fever, 150. 

in typhus fever, 278. 
Delirious variety of pernicious fever, 

91. 
Delirium in pernicious fever, 93. 

in scarlet fever, 414. 

in small-pox, 341. 

in typhoid fever, 158, 

in typho-malarial fever, 115. 

in typhus fever, 283. 

in yellow fever, 208. 
Dengue fever, chart of, 107. 

clinical history of, 104. 

definition of, 103. 

differential diagnosis of, 108. 

duration of, 105. 

etiology of, 104. 

history of, 104. 

prognosis of, 108. 

synonyms of, 104. 

treatment of , 108. 



Desiccation in small-pox, 338. 
Destitution, as predisposing to re- 
lapsing fever, 309 

to typhus fever, 274. 
Desquamation, in measles, 382. 

in relapsing fever, 320. 

in scarlet fever, 409. 
Diarrhea, in chronic malarial infec- 
tion, 101. 

in relapsing fever, 318. 

in scarlet fever, 419. 

in typhoid fever, 150. 

in typho-malarial fever, 115. 
Diet, in cerebro-spinal fever, 251. 

in chdcken-pox, 374. 

in influenza, 275. 

in measles, 398. 

in miliary fever, 378. 

in pernicious fever, 99. 

in relapsing fever, 329. 

in scarlet fever, 438 

in simple intermittent fever, 75. 

in typhoid fever, 192. 

in typhus fever, 304. 

in yellow fever, 221. 
Difference between bacteria of con- 
tagion and bacteria of putrefac- 
tion, 21. 
Differential diagnosis, of cerebro- 
spinal fever, 235. 

of chicken-pox, 372. 

of chronic malarial infection, 102. 

of dengue, 108. 

of german measles, 402. 

of hay fever, 129. 

of influenza, 259. 

of measles, 390. 

of miliary fever, 376. 

of pernicious fever, 96. 

of relapsing fever, 322. 

of scarlet fever, 422. 

of simple continued fever, 33. 

of simple intermittent fever, 55. 

of simple remittent fever, 83. 

of small-pox, 348. 

of typhoid fever, 165. 

of typho-malarial fever, 118. 

of typhus fever, 291. 

of yellow fever, 210. 



INDEX. 



U9 



Digestive system, condition of, in ' 
cerebro-spinal fever, 232. 

in chronic malarial infection, 115. 

in dengne, 106. 

in influenza, 258. 

in measles, 388. 

in pernicious fever, 95. 

in relapsing fever, 317. 

in scarlet fever, 418. 

in simple intermittent fever, 54. 

in simple remittent fever, 82. 

in small-pox, 345. 

in typhoid fever, 148. 

in typho-malarial fever, 115. 

in typhus fever, 288. 

in yellow fever, 203. 
Dimensions of bacteria, 17. 
Diphtheria, as a complication of 

scarlet fever, 412. 
Disinfectants, in the treatment of 
relapsing fever, 324. 

of scarlet fever, 425. 

of small-pox, 351. 

of typhoid fever, 172. 

of typhus fever, 293. 

of yellow fever, 231. 
Dropsy, scarlatinal, 411. 

treatment of, 428. 
Drinking water, contamination of, 
in scarlet fever, 406. 

in typhoid fever, 141. 
Duodenum, lesions of, in typhoid fe- j 
ver, 163. 

in scarlet fever. 422. 
Dura mater, condition of, in cerebro- \ 
spinal fever, 234. 

in typhoid fever, 163. 
Dyspnoea, of cerebro-spinal fever, 
226. 

of hay fever, 129. 

of influenza, 258. 

of miliary fever, 375. 
Ear, disorders of, in cerebro-spinai 
fever, 229. 

in scarlet fever, 420. 

in small-pox, 341. 

in typhoid fever, 159. 

in typhus fever, 2S4. 
Eczema, after vaccination, 363. 



Emaciation, in dengne, 108. 

in typhoid fever, 157. 
Endocarditis, in cerebro-spinal fe- 
ver, 233. 

in small-pox, 383. 
Epididymitis, in dengue, 106. 

in small-pox, 346. 
Epistaxis, in typhoid fever. 159. 
Eruption, of cerebro-spinal fever, 
231. 

of chicken-pox, 371. 

of dengue, 106. 

of german measles, 400. 

of measles, 387. 

of miliary fever, 376, 

of relapsing fever, 320. 

of scarlet fever, 420. 

of small-pox, 343. 

of typhoid fever, 157. 

of typhus fever, 2S7. 

of varioloid, 368. 
Erysipelas, after vaccination, 363. 
Erythema, in cerebro-spinal fever, 

231. 
Etiology, of cerebro-spinal fever, 224. 

of chronic malarial infection, 100. 

of chicken-pox, 371. 

of cow-pox, 360. 

of dengue, 104. 

of german measles, 399. 

of hay fever, 124. 

of influenza, 254. 

of measles, 380. 

of miliary fever, 375. 

of pernicious fever, 90. 

of relapsing fever, 309. 

of scarlet fever, 405. 

of simple continued fever, 29. 

of simple intermittent fever, 49. 

of simple remittent fever, 76. 

of small-pox, 334. 

of typhoid fever, 137. 

of typho-malarial fever, 112 

of typhus fever, 274. 

of varioloid, 368. 

of yellow fever, 196. 
Excreta, decomposing, in etiology of 

typhoid fever, 141. 
Eye, condition of, in cerebro-spinal 



150 



INDEX. 



fever, 226. 

in hay fever, 127. 

ininnuecza, 225. 

in measles, 381. 

in relapsing fever, 313. 

in scarlet fever, 419. 

in small-pox, 341. 

in typhoid fever, 159. 

in typhus fever, 284. 

in yellow fever, 205. 
Fever, ardent continued, 30. 

asthenic simple, 31. 

cerebro-spinal, 223. 

dengue, 103. 

ephemeral continued, 30. 

miliary, 374. 

pernicious, 89. 

scarlet, 404. 

simple intermittent, 48. 

simple remittent, 76. 

synochal continued , 30. 

relapsing, 307. 

typhoid, 135. 

typhus, 272. 

yellow, 195. 
Fevers, classification of, 28. 

contagious, definition of, 28. 

introduction to, 15. 

malarial, 35. 

miasmatic, 27. 

miasmatic, contagious, 27. 
Fomites, in measles, 380. 

in relapsing fever, 311. 

in scarlet fever, 406. 

in small-pox, 335. 

in typhoid fever, 139. 

in typhus fever, 274. 

in yellow fever, 199. 
Forms of bacteria, 17. 
Fresh air in treatment, of scarlet fe- 
ver, 438. 

of small-pox, 358. 

of typhoid fever, 190. 

of typhus fever, 304. 

of yellow fever, 221. 
Gangrene, of lung, in typhus fever, 
290. 

of tonsils, in scarlet fever, 421 . 
Geographical limits, of malarial fe- 



vers, 37. 

of simple remittent fever, 77. 

of typhoid fever, 137. 

of typhus fever, 273. 

of yellow fever, 196. 
Germs, of cerebro-spinal fever, 225. 

of malarial fevers, 18, 39. 

of measles, 380. 

of influenza, 255. 

of relapsing fever, 310. 

of scarlet fever, 405. 

of small-pox, 334. 

of typhoid fever, 138. 

of typho-malarial fever, 112. 

of typhus fever, 274. 

of yellow fever, 197. 
German measles, chart of, 401. 

clinical history of, 400. 

definition of, 399. 

differential diagnosis of, 402. 

duration of, 402. 

etiology of, 399. 

history of, 399. 

morbid anatomy of, 402. 

prognosis of, 403. 

synonyms of, 399. 

treatment of, 403. 
Glandular enlargements, in dengue, 
106. 

in typhus fever, 280. 
Glandular inflammation in scarlet 

fever, 417. 
Gurgling in right iliac fossa, in ty- 
phoid fever, 151. 
Hematuria, in pernicious fever, 97. 

in scarlet fever, 419. 

in small-pox, 346. 
Hair, falling of, in scarlet fever, 418. 

in typhoid fever, 157. 

in typhus fever, 279. 
Hay fever, asthmatic form of, 126. 

catarrhal form of, 125. 

chart of, 128. 

clinical history of, 125. 

definition of, 123. 

differential diagnosis of, 129. 

etiology of, 124. 

history of, 123. 

prognosis of, 130. 



INDEX. 



451 



synonyms of, 123. 

treatment of, 130. 

varieties of, 125. 
Headache, in cerebro-spinal fever, 
227. 

in chicken-pox, 371. 

in dengue, 106. 

in german measles, 400. 

in influenza, 256. 

in measles, 386. 

in miliary fever, 375. 

in pernicious fever, 90. 

in relapsing fever, 315. 

in scarlet fever, 414. 

in simple intermittent fever, 53. 

in simple remittent fever, 80. 

in small-pox, 341. 

in typhoid fever, 158. 

in typho-malarial fever, 115. 

in typhus fever, 281. 

in varioloid, 368. 

in yellow fever, 206. 
Hearing, disturbance of, in cerebro- 
spinal fever, 229. 

in chronic malarial infection, 102. 

in measles, 384. 

in scarlet fever, 413. 

in small-pox, 341. 

in typhoid fever, 159. 

in typhus fever, 284. 
Heart, changes in, in chronic mala- 
rial infection, 101. 

in relapsing fever, 321. 

in typhoid fever, 162. 

in typho-malarial fever, 117. 

in typhus fever, 290. 

in yellow fever, 209. 

condition of, in cerebro-spinal fe- 
ver, 233. 
Hemiplegia in chronic malarial in- 
fection, 101. 
Hemorrhage, in pernicious fever, 92. 

in typho-malarial fever, 115. 

from intestines, in typhoid fever, 
151. 
Herpes, in cerebro-spinal fever, 231. 

in influenza, 258. 

in simple continued fever, 33. 
History of bacteria, 16. 



of cerebro-spinal fever, 223. 

of chicken-pox, 371. 

of cow-pox, 360. 

of dengue, 104. 

of german measles, 399. 

of hay fever, 123. 

of hypodermatic medication, 98. 

of influenza 253. 

of inoculation, 364. 

of measles, 379. 

of miliary fever, 374. 

of pernicious fever, 89. 

of relapsing fever, 308. 

of scarlet fever, 404. 

of simple intermittent fever. 48. 

of simple remittent fever, 76. 

of small-pox, 332. 

of typhoid fever, 136. 

of typho-malarial fever, 112. 

of typhus fever, 273. 

of vaccination, 365. 

of yellow fever, 195. 
Horse-pox, 361 . 

Hydrocephalus, chronic, after cere- 
bro-spinal fever, 227. 

after scarlet fever, 412. 
Hygienic treatment, of cerebro-spi- 
nal fever, 251. 

of chicken-pox, 372. 

of chronic malarial infection, 102. 

of dengue, 108. 

of german measles, 403. 

of hay fever, 130. 

of influenza, 271. 

of measles, 397. 

of miliary fever, 378. 

of pernicious fever, 99. 

of relapsing fever, 329. 

of scarlet fever, 438. 

of simple continued fever, 34. 

of simple intermittent fever, 75. 

of small-pox, 359. 

of typhoid fever, 190. 

of typho-malarial fever, 121. 

of typhus fever, 304. 

of yellow fever, 221. 
Hyperesthesia, in cerebro-spinal fe- 
ver, 231. 

in typhoid fever 159. 



452 



INDEX. 



Hypochondriasis, in chronic malarial 

infection, 101. 
Hypodermatic medication, in cere- 
brospinal fever, 252. 

in pernicious fever, 98. 

in simple intermittent fever, 59. 
Hysteria, in typhoid fever, 158. 
Ice-water injections into rectum in 

urinary retention. 221, 
Icteric variety of pernicious fever, 

93. 
Ileum, lesions of, in typhoid fever. 

162. 
Infarctions, in kidneys, in typhoid 
fever, 162. 

in spleen, in relapsing fever, 321. 
Influenza, chart of, 257. 

clinical history of, 255. 

definition of, 253. 

differential diagnosis of, 259. 

etiology of, 254. 

history of, 253- 

morbid anatomy of, 259. 

prognosis of, 259. 

synonyms of, 253. 

treatment of, 259. 
Inoculation, clinical history of, 364. 

definition of, 364. 

history of, 364. 

mortality of, 365- 
Insomnia in typhus fever, 283. 
Instrument for hypodermatic injec- 
tions, 98. 
Intermittent fever, neuralgia in, 51. 
Intestinal canal, lesions of, in mea- 
sles, 389. 

in miliary fever, 376. 

in pernicious fever, 96. 

in relapsing fever, 321. 

in simple remittent fever, 83. 

in typlioid fever, 163. 

in typho-malarial fever. 117. 
Introductory, 15. 
Inunctions, in measles, 398. 

in scarlet fever, 439. 

in small-pox. 359. 
Iron cough in measles, 386. 
Jaundice, in bilious remittent fever, 
80. 



in cerebro-spinal fever, 233. 

in pernicious fever, 93. 

in relapsing fever, 318. 

hematogenous, in yellow fever r 
203. 
Jenner, vaccination and, 365, 
Joints, affection of, in dengue, 108. 

inflammation of, in cerebro-spinal 
fever, 231. 

in scarlet fever, 413. 
Kidneys, lesions of, in cerebro-spinal 
fever, 234. 

in chronic malarial infection, 101. 

in pernicious fever, 92. 

in relapsing fever. 321. 

in scarlet fever, 421. 

in typhoid fever, 162. 

in typho-malarial fever, 117. 

in typhus fever, 290. 

in yellow fever, 208. 
Koch, experiments of, concerning 

bacteria, 23 
Koumyss, in treatment of typlioid 

fever, 193. 
Laryngitis, in influenza, 258. 

in typhoid fever. 279. 
Leeuwenhoek first to observe bacte- 
ria, 16. 
Liver, changes in, in chronic mala- 
rial infection, 102. 

in pernicious fever, 93. 

in relapsing fever, 321. 

in scarlet fever, 422. 

in simple intermittent fever, 55. 

in simple remittent fever, 83 

in typhoid fever, 162. 

in typho-malarial fever, 117. 

in typhus fever, 290. 

in yellow fever, 208. 
Lungs, changes in, cerebro-spinal fe- 
ver, 233. 

in german measles, 400. 

in influenza, 258. 

in measles 389. 

in pernicious fever, 93. 

in relapsing fever 321. 

in tyj^hoid fever, 162. 

in typhus fever, 290. 



INDEX. 



453 



Xiymphatic glands, enlargement of, 

in dengue, 106. 
Malaria, conditions favorable to the 
development of, 42. 
climatic influences in the genesis 

of, 44. 
geographical limits of, 37. 
incubation of, 41. 
susceptibility to, 41. 
the laws of, 40. 
Malarial fevers, character of, 36. 
microscopical appearance of blood 

in, 55. 
geographical limits of, 37. 
origin of, 37. 
Malignant measles, 383. 
Mania, in cerebro-spinal fever, 2:9. 
in scarlet fever, 414. 
in small-pox, 341. 
in typhoid fever, 158. 
in typhus fever, 283. 
Marson's statistics of vaccination 

366. 
Martin's statistics of animal vaccin- 
ation, 367. 
Massage, in treatment of dengue, 109. 
Measles, bacteriform elements in, 
22, 180. 
chart of, 3S5. 
clinical history of, 381. 
complications of, 384. 
definition of, 379. 
differential diagnosis of, 390. 
duration of, 383. 
etiology of, 3S0. 
history of, 379. 
incubation of, 380. 
irregular types of, 383. 
morbid anatomy of, 38S. 
prognosis of, 391. 
sequels of, 3S4. 
synonyms of, 379. 
treatment of, 391. 
Meat-pancreas injections in typhoid 

fever, 193. 
Meningitis, as a complication of ty- 
phus fever, 2S0. 
Memory, weakness of, after cerebro- 
spinal fever, 233. 



Mesenteric glands, changes in, in 
typhoid fever, 165. 

in typho-malarial fever, 118. 

in simple remittent fever, 83. 

in scarlet fever, 422. 
Meteorism in typhoid fever, 152. 
Miasm, definition of, 27. 

nature of, 38. 
Miasmatic fevers, definition of, 27. 
Miasmatic-contagious fevers, defini- 
tion of, 27. 
Micrococcus, description of, 17. 
Miliary fever, chart of, 377. 
clinical history of, 375. 

definition of, 374. 

differential diagnosis of, 376. 

duration of, 376. 

etiology of, 375. 

history of, 374. 

morbid anatomy of. 376. 

prognosis of, 378. 

synonyms of , 374. 

treatment of. 378. 
Mild typhoid fever, 147. 
Milk, in etiology of scarlet fever, 
406. 

in etiology of typhoid fever, 142. 

in treatment of typhoid fever, 192. 
Montague, lady, on small-pox inocu- 
lation, 364. 
Morbid anatomy, of cerebro-spinal 
fever, 233. 

of chronic malarial infection, 101. 

of german measles, 402. 

of influenza, 259. 

of measles, 388. 

of pernicious fever, 96. 

of relapsing fever, 320. 

of scarlet fever, 420. 

of simple intermittent fever, 54. 

of simple remittent fever, 82. 

of small-pox, 347. 

of typhoid fever, 160. 

of typho-malarial fever, 117. 

of typhus fever, 289. 

of yellow fever, 208. 
Muscles, changes in, in cerebro-spi- 
nal fever, 234. 

in typhoid fever, 163. 



454 



INDEX. 



in typhus fever, 290. 

contraction of, in cerebro-spinal 
fever, 230. 

paralysis of, in typhoid fever, 159. 

in typhus fever, 284. 
Nausea, in cerebro-spinal fever, 233. 

in dengue, 106. 

in german measles, 400. 

in influenza, 258. 

in measles, 388. 

in relapsing fever, 317. 

in scarlet fever, 419. 

in simple intermittent fever, 54. 

in simple remittent fever, 82. 

in small-pox, 346. 

in typhoid fever, 150. 

in typho-malarial fever, 115. 

in typhus fever, 288. 

in yellow fever, 203. 
Neck, stiffness of, in cerebro-spinal 

fever, 230. 
Neuralgia, in chronic malarial infec- 
tion, 101. 

in influenza, 257. 

in relapsing fever, 315. 
Nitrogen, how obtained by bacteria, 

20. 
Odor of skin, in scarlet fever, 418. 

in simple intermittent fever, 54. 

in small-pox, 338. 

in typhus fever, 278. 

in yellow fever, 200. 
Occupation, in etiology of typhoid 
fever, 138. 

in etiology of typhus fever, 274. 
(Edema, of glottis, in scarlet fever, 

412. 

pulmonary, in typhoid fever, 162. 
Orchitis, in small-pox, 346. 
Origin, of bacteria, 20. 

of new diseases in the world, 21. 
Overcrowding, in etiology of relaps- 
ing fever, 309. 

in etiology of typhus fever, 274. 
Ozone, action of, upon bacteria, 20. 
Pain, in cerebro-spinal fever, 231. 

in chronic malarial infection, 101. 

in dengue, 108. 

in influenza, 256. 



in relapsing fever, 315. 

in simple intermittent fever, 54. 

in simple remittent fever, 77. 

in small-pox, 341. 

in typhoid fever, 158. 

in typho-malarial fever, 115. 

in typhus fever, 283. 

abdominal, in typhoid fever, 151., 
Paralysis, after cerebro-spinal fever, 
229. 

after relapsing fever, 317. 

in cerebro-spinal fever, 229. 

in typhoid fever, 159. 

in typhus fever, 284. 
Parasitic theory of disease, 24. 
Parotitis, in cerebro-spinal fever,, 
233 

in influenza, 258. 

in typhoid fever, 150. 
Particle, definition of, 21. 
Pasteur, on attenuation of viruses, 

365. 
Patient, attitude of, in cerebro-spinal 

fever, 230. 
Pea-soup discharges, in typhoid fe- 
ver, 144. 
Perforation, intestinal, in typhoid 

fever, 151. 
Pernicious fever, chart of, 94. 

clinical history of, 90. 

definition of. 89. 

differential diagnosis of, 96. 

etiology of, 90. 

history of, 89. 

hypodermatic medication in, 98. 

morbid anatomy of, 96. 

prognosis of, 97. 

synonyms of 89. 

treatment of, 97. 

varieties of, 90. 
Petechia, in cerebro-spinal fever r 
231. 

in scarlet fever, 421 . 

in typhus fever, 288. 
Physiognomy, in pernicious fever, 
91. 

in small-pox, 345. 

in typhoid fever, 157. 

in yellow fever, 203. 



INDEX. 



455 



Pia mater, condition of, in cerebro- 
spinal fever, 234. 
Place of bacteria in vegetable series, 

16. 
Plax scindens, description of, 22, 
405. 

in scarlet fever, 405. 
Pleurisy, in cerebro-spinal fever, 233. 
Pneumonia, as a complication of in- 
fluenza, 258. 

in cerebro-spinal fever, 233. 

in measles, 386. 

in relapsing fever, 321. 

in typhoid fever. 162. 

in typhus fever, 28S. 
Pollen, in etiology of hay fever, 124. 
Pregnancy, in typhoid fever, 171. 
Prevention of pitting in small-pox, 

359. 
Projectile vomiting, in scarlet fever. 
408. 

in yellow fever, 302. 
Prognosis, in cerebro-spinal fever. 
237. 

in chicken-pox, 37:2. 

in chronic malarial infection, 102. 

in dengue, 108. 

in german measles, 403. 

in measles 391. 

in miliary fever, 378. 

in pernicious fever, 97. 

in relapsing fever, 324. 

in scarlet fever, 424. 

in simple continued fever, 34. 

in simple intermittent fever, 56. 

in simple remittent fever, 84. 

in small-pox, 350. 

in typhoid fever, 169. 

in typho-malarial fever, 119. 

in typhus fever, 292. 

in varioloid, 370. 

in yellow fever, 211. 
Prophylaxis, in cerebro-spinal fever, 
239. 

in chicken-pox, 372. 

in chronic malarial infection, 102. 

in dengue, 108. 

in german measles, 403. 

in hay fever, 130. 



in influenza, 259. 

in measles, 391. 

in miliary fever, 378. 

in pernicious fever, 87. 

in relapsing fever, 324. 

in scarlet fever, 425. 

in simple continued fever, 34. 

in simple intermittent fever, 58. 

in simple remittent fever, 85. 

in small-pox, 350. 

in typhoid fever, 172. 

in typho-malarial fever, 119. 

in typhus fever, 293. 

in varioloid, 370. 

in yellow fever, 211. 
Pulse, in cerebro-spinal fever, 232. 

in chronic malarial infection, 101. 

in dengue, 105. 

in influenza, 256. 

in measles, 387. 

in miliary fever, 375. 

in pernicious fever, 95. 

in relapsing fever, 318. 

in scarlet fever, 416. 

in simple continued fever, 31. 

in simple intermittent fever, 54. 

in simple remittent fever, 80. 

in small-pox, 343. 

in typhoid fever, 156. 

in typho-malarial fever, 117. 

in typhus fever, 287. 

in yellow fever, 206. 
Punch, whisky or brandy, formula 

for, 306. 
Pupil, condition of, in cerebro-spinal 

fever, 229. 
Putrifaction, role of bacteria in, 20. 
Quarantine, in small-pox, 351. 

in relapsing fever, 324. 

in typhus fever, 293. 

in yellow fever, 212. 
Race, influence of, in hay fever, 124. 

in yellow fever, 198. 
Recrudescences of fever, in typhoid 

fever, 146. 
Relapses, in dengue, 105. 

in miliary fever, 375. 

in relapsing fever, 279. 

in typhoid fever, 160. 



456 



INDEX. 



in typho-malarial fever, 115. 

in typhus fever, 272. 
Eelapsing fever, bacteria in, 310. 

chart of, 316. 

clinical history of, 312. 

complications of, 315. 

definition of, 307. 

differential diagnosis of, 322. 

etiology of, £.09 . 

history of, 308. 

morbid anatomy of, 320. 

prognosis of, 321. 

treatment of, 324. 
Renal complications, in relapsing fe- 
ver, 320. 

in scarlet fever, 419. 

in small-pox, 341. 

in yellow fever, 205. 
Remedies used hypodermatically, 98. 
Reproduction of bacteria, 20. 
Respiration of bacteria, 20. 
Respiratory system, condition of, in 
cerebro-spinal fever, 232. 

in typhoid fever, 156. 
Retinitis, in relapsing fever, 315. - 
Re-vaccination, 367. 
Role of bacteria in causation of dis- 
ease, 22. 
Salivary glands, changes in, in ty- 
phoid fever, 163. 
Scarlet fever, chart of, 415. 

bacteria in blood of, 421. 

bacteria in urine of, 419. 

clinical history of, 407. 

complications and sequels of, 411. 

definition of, 404. 

differential diagnosis of, 422. 

duration of, 409. 

etiology of, 405. 

history of, 404. 

incubation of, 406. 

in the lower animals, 406. 

morbid anatomy of, 420. 

plax scindens in etiology of, 405. 

prognosis of, 424. 

synonyms of, 404. 

treatment of, 425. 
Schizomycetes, in cerebro-spinal fe- 
ver. 22, 234. 



Season of year as predisposing influ- 
ence in cerebro-spinal fever, 224. 

in hay fever, 124. 

in typhoid fever,' 137. 

in typhus fever, 274. 

in yellow fever, 198. 
Secondary fever, in relapsing fever, 
314. 

in small-pox, 338. 
Sewer-gas, as a cause of typho-mala- 
rial fever, 112. 
Simple continued fever, chart of, 32. 

clinical history of, 29. 

definition of, 29. 

diagnosis of, 33. 

duration of, 30. 

etiology of, 29. 

prognosis of, 34. 

synonyms of, 29. 

treatment of, 34. 

varieties of, 30. 
Simple intermittent fever, chart of, 
53. 

clinical history of , 49. 

bacillus malarise in, 49. 

definition of , 48. 

differential diagnosis of, 55. 

etiology of, 49. 

history of, 48. 

morbid anatomy of, 54. 

prognosis of, 56. 

synonyms of, 48. 

treatment of, 57. 
Simple remittent fever, chart of, 81. 

clinical history of, 77. 

bacillus malarise in, 77. 

definition of, 76. 

difierential diagnosis of, 83. 

duration of , 85. 

etiology of, 76. 

historical notice of, 76. 

morbid anatomy of, 82. 

prognosis of, 84. 

synonyms of, 76. 

treatment of, 85. 
Skin, appearance of, in cerebro-spi- 
nal fever, 231. 

in chicken-pox, 371. 

in chronic malarial infection, 101. 



INDEX. 



m 



in dengue, 106. 

in german measles, 400. 

in influenza, 258. 

in measles, 387. 

in miliary fever, 376. 

in pernicious fever, 95. 

in relapsing fever, 320. 

in scarlet fever, 418. 

in simple intermittent fever, 49. 

in simple remittent fever, 78. 

in small-pox, 345. 

in typhoid fever, 157. 

in typho-malarial fever, 117. 

in typhus fever, 287. 

in varioloid, 368. 

in yellow fever, 203. 

bronzed hue of, in typho-malarial 
fever, 117. 
Sleeplessness, in cerebro-spinal fe- 
ver, 228. 

in typhus fever, 283. 
Small-pox, chart of, 342. 

clinical history of, 336. 

complications of, 341. 

definition of, 331. 

differential diagnosis of, 348. 

duration of, 341. 

etiology of, 334. 

eruption of, 343. 

history of, 332. 

incubation of, 335. 

inoculation in, 364. 

micrococci in, 23, 334. 

morbid anatomy of, 347. 

prognosis of, 350. 

synonyms of, 332. 

treatment of, 350. 

vaccination in, 365. 
Somnolence in typhoid fever, 15S. 
Sordes in typhoid fever, 150. 
Spirillum, description of, 17, 310. 

in relapsing fever, 310. 
Spirochseti, 18, 310. 
Spine, contraction of erector muscles 

of, in cerebro-spinal fever, 230. 
Spleen, changes in, in chronic mala- 
rial infection, 101. 

in measles, 389. 

in miliary fever, 376. 



in relapsing fever, 321. 

in scarlet fever. 422. 

in simple remittent fever, 83. 

in typhoid fever, 162. 

in typho-malarial fever, 117. 

in typhus fever, 290. 
Spongiug, in dengue, 109. 

in german measles, 403. 

in measles, 398. 

in scarlet fever, 439. 

in small-pox, 359. 

in typhoid fever, 192. 

in typhus fever, 305. 

in yellow fever, 221. 
Stimulants, in cerebro-spinal fever, 
252. 

in influeuza, 271. 

in measles, 398. 

in pernicious fever, 99. 

in relapsing fever, 329. 

in scarlet fever, 438. 

in small-pox, 359. 

in typhoid fever, 194. 

in typho-malarial fever, 121. 

in typhus fever, 305. 

in yellow fever, 221. 
Stomach, changes in, in relapsing 
fever, 321. 

in simple remittent fever, 83. 

in typhoid fever, 163. 

in yellow fever, 209. 
Structure of bacteria, 16. 
Sudamina, in cerebro-spinal fever, 
231. 

in typhoid fever, 157. 
Sulphate of quinine, action of, upon 

bacteria, 59. 
Suppression of urine, in scarlet fe- 
ver, 419. 

in small-pox, 346. 

in typhoid fever, 158. 

in typhus fever, 289. 

in yellow fever, 205. 
Temperature, in cerebro-spinal fe- 
ver, 231. 

in dengue, 105. 

in influenza, 256. 

in measles, 386. 

in miliary fever, 375. 



458 



INDEX. 



in pernicious fever, 95. 

in relapsing fever, 318. 

in simple continued fever, 31. 

in simple intermittent fever, 54. 

in simple remittent fever, 80. 

in scarlet fever, 416. 

in small-pox, 336. 

in typhoid fever, 152. 

in typho-malarial fever, 117. 

in typhus fever, 284. 

in yellow fever, 206. 
Tents, in treatment, of typhus fever, 
304. 

of yellow fever, 212. 
The parasitic theory, 24. 
The bacillus malarise, 18, 24, 39. 
The tubercle bacillus, 23. 
Thirst, in cerebro-spinal fever, 233. 

in measles, 388. 

in pernicious fever, 95. 

in relapsing fever, 317. 

in scarlet fever, 419. 

in simple intermittent fever, 54. 

in simple remittent fever, 82. 

in small-pox. "346. 

in typhoid fever, 150. 

in typhus fever, 289. , 
Thermometry of fevers, 46. 
Tongue, state of, in cerebro-spinal 
fever, 232. 

in chronic malarial infection, 101. 

in dengue, 106. f 

in german measles, 400. 

in influenza, 258. 

in measles, 388. 

in pernicious fever, 95. 

in relapsing fever, 317. 

in scarlet fever, 418. 

in simple intermittent fever, 54. 

in simple remittent fever, 82. 

in small-pox, 345. 

in typhoid fever, 148. 

in typho-malarial fever, 115. 

in typhus fever, 289. 

in yellow fever, 203. 
Tremor in typhoid fever, 159. 
Trismus in cerebro-spinal fever, 230. 
Treatment, of cerebro-spinal fever, 
239. 



of chicken-pox, 372. 

of chronic malarial infection, 102. 

of dengue, 108. 

of german measles, 403. 

of hay fever, 130. 

of influenza, 259. 

of measles, 391. 

of miliary fever, 378. 

of pernicious fever, 97. 

of relapsing fever, 324. 

of simple continued fever, 34. 

of simple intermittent fever 57. 

of simple remittent fever, 85. 

of scarlet fever, 425. 

of small-pox, 350. 

of typhoid fever, 172. 

of typho-malarial fever, 119. 

of typhus fever, 293. 

of varioloid, 370. 

of yellow fever, 211. 
Tympanites, in typhoid fever, 152. 
Types, of simple intermittent fever, 
51. 

of typho-malarial fever, 112. 
Typhoid fever, abortive form of, 147. 

bacteria in, 138. 

chart of, 149. 

clinical history of, 142. 

definition of, 136. 

differential diagnosis of, 165. 

duration of, 159. 

etiology of, 137. 

geographical distribution of, 137. 

history of, 136. 

incubation of, 140. 

mild form of, 147. 

morbid anatomy of, 160. 

prognosis of, 169. 

synonyms of, 136. 

treatment of, 172. 
Typho-malarial fever, chart of, 116. 

clinical history of, 112. 

complications of, 114. 

definition of, 111. 

differential diagnosis of, 118. 

duration of , 115. 

etiology of, 112. 

history of, 112. 

malarial type of, 112. 



INDEX. 



459 



morbid anatomy of, 117. 

prognosis of, 119. 

septic type of, 113. 

synonyms of, 112. 

treatment of, 119. 
Typhus fever, chart of, 282. 

clinical history of, 276. 

complications of, 279. 

definition of, 272. 

differential diagnosis of. 291. 

duration of, 281. 

etiology of, 274. 

geographical limits of, 273. 

history of. 273. 

incubation of, 275. 

morbid anatomy of, 2S9. 

prognosis of, 292. 

synonyms of, 272. 

treatment of, 293. 
Urine, changes in, in cerebro-spinal 
fever, 233. 

in chronic malarial infection, 101. 

in influenza, 258. 

in measles, 388. 

in miliary fever, 375. 

in relapsing fever, 320. 

in scarlet fever, 419. 

in simple continued fever, 33. 

in simple intermittent fever, 54. 

in simple remittent fever, 78. 

in small-pox, 346. 

in typhoid fever, 158. 

in typho-malarial fever, 114. 

in typhus fever, 289. 

in yellow fever, 205. 
Urticaria, in cerebro-spinal fever, 
231. 

in dengue, 106. 
Vaccination, definition of, 365. 

history of, 365. 

mortality by small-pox after, 367. 

period of performance of, 366. 

prophylactic influence of, 365. 

statistics of, 366. 

surgery of, 367. 
Vaccinia, definition of, 361. 

clinical history of, 361. 

complications of, 363. 

irregularities of, 362. 



synonyms of, 361. 
Variable pulse, in cerebro-spinal fe- 
ver, 232. 
Variations of relapsing fever, 312. 
Varioloid, chart of, 369. 

clinical history of, 368. 

definition of, 368. 

differential diagnosis of, 370. 

duration of, 370. 

etiology of, 368. 

prognosis of, 370. 

synomym of, 368. 

treatment of 370. 
Vertigo, in cerebro-spinal fever, 229. 

in relapsing fever, 315. 

in small-pox, 341. 

in typhus fever, 281. 
Vibrios, description of, 19. 
Virus, vaccine, 366. 
Viruses, 15. 

Vomiting, in cerebro-spinal fever, 
333. 

in chicken-pox, 371. 

in dengue, 105. 

in influenza, 258. 

in measles, 388. 

in pernicious fever, 95. 

in relapsing fever, 317. 

in scarlet fever, 419. 

in simple intermittent fever, 54. 

in simple remittent fever, 82. 

in small-pox, 346. 

in typhoid fever, 150. 

in typho-malarial fever, 115. 

in typhus fever, 288. 

in yellow fever, 205. 
Waterhouse, the first American vac- 
cinator, 365. 
Waters which do not contain bacte- 
ria, 21. 
Weight of body, changes in, in ty- 
phoid fever, 157. 

in relapsing fever, 314. 
Wine-whey, formula for, 194. 
Yellow fever, chart of, 204. 

clinical history of, 200. 

definition of, 195. 

differential diagnosis of, 210. 

duration of, 203. 



460 



etiology of, 196. 
geographical limits of, 196. 
history of, 195. 
incubation of, 200. 



INDEX. 



morbid anatomy of, 208. 
prognosis of, 211. 
synonyms of, 195. 
treatment of, 211. 



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